Provider Demographics
NPI:1801188693
Name:ANDERSON, RICHARD WARREN
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:WARREN
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 1/2 MYRTLE ST
Mailing Address - Street 2:APARTMENT 3
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-4531
Mailing Address - Country:US
Mailing Address - Phone:513-755-8871
Mailing Address - Fax:
Practice Address - Street 1:28 1/2 MYRTLE ST
Practice Address - Street 2:APARTMENT 3
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-4531
Practice Address - Country:US
Practice Address - Phone:513-755-8871
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-11
Last Update Date:2013-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MAL-248702207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program