Provider Demographics
NPI:1790916450
Name:ANDERSON, DONALD K (MD)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:K
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 340
Mailing Address - Street 2:
Mailing Address - City:DEWITTVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14728-0340
Mailing Address - Country:US
Mailing Address - Phone:716-753-7426
Mailing Address - Fax:
Practice Address - Street 1:8 SENECA
Practice Address - Street 2:CHAUTAUQUA LAKES ESTATES
Practice Address - City:DEWITTVILLE
Practice Address - State:NY
Practice Address - Zip Code:14728
Practice Address - Country:US
Practice Address - Phone:716-753-7426
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-29
Last Update Date:2009-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY098434-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00591162Medicaid
NY00591162Medicaid