Provider Demographics
NPI:1790823458
Name:ANDERSON, LLOYD T (MD)
Entity Type:Individual
Prefix:
First Name:LLOYD
Middle Name:T
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 1:1021 E BRYAN AVE
Mailing Address - Street 2:
Mailing Address - City:SAPULPA
Mailing Address - State:OK
Mailing Address - Zip Code:74066-4512
Mailing Address - Country:US
Mailing Address - Phone:918-227-1000
Mailing Address - Fax:918-403-6314
Practice Address - Street 1:1021 E BRYAN AVE
Practice Address - Street 2:
Practice Address - City:SAPULPA
Practice Address - State:OK
Practice Address - Zip Code:74066-4512
Practice Address - Country:US
Practice Address - Phone:918-227-1000
Practice Address - Fax:918-403-6314
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2018-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK9511207P00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100105090AMedicaid
OK242712301Medicare PIN
OK100105090AMedicaid