Provider Demographics
NPI:1821106071
Name:ANDERSON, KENT W (MD)
Entity Type:Individual
Prefix:
First Name:KENT
Middle Name:W
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 1829
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83816-1829
Mailing Address - Country:US
Mailing Address - Phone:208-667-9334
Mailing Address - Fax:208-664-2341
Practice Address - Street 1:504 6TH ST
Practice Address - Street 2:DEPARTMENT OF RADIATION ONCOLOGY
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-2439
Practice Address - Country:US
Practice Address - Phone:208-799-5600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM55762085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1124420Medicare ID - Type UnspecifiedCIGNA
D33631Medicare UPIN