Provider Demographics
NPI:1790813442
Name:ANDERSON, DANIEL RICHARD (MD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:RICHARD
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 279
Mailing Address - Street 2:
Mailing Address - City:WINAMAC
Mailing Address - State:IN
Mailing Address - Zip Code:46996-0279
Mailing Address - Country:US
Mailing Address - Phone:574-946-2194
Mailing Address - Fax:
Practice Address - Street 1:540 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:WINAMAC
Practice Address - State:IN
Practice Address - Zip Code:46996-1173
Practice Address - Country:US
Practice Address - Phone:574-946-2194
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLL28992208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201204820Medicaid