Provider Demographics
NPI:1801828116
Name:ANDERSON, MARY NELL (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:NELL
Last Name:ANDERSON
Suffix:
Gender:F
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 53904
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70505-3904
Mailing Address - Country:US
Mailing Address - Phone:225-769-5554
Mailing Address - Fax:
Practice Address - Street 1:7777 HENNESSY BLVD
Practice Address - Street 2:STE 706
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-4300
Practice Address - Country:US
Practice Address - Phone:225-769-5554
Practice Address - Fax:225-757-1959
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2008-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA017212208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1375896Medicaid
LA1375896Medicaid
B65008Medicare UPIN