Provider Demographics
NPI:1821145368
Name:ANDERSON, MARK A (PT, PHD, ATC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:PT, PHD, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 NE 13TH ST
Mailing Address - Street 2:ROOM 239
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73104-5005
Mailing Address - Country:US
Mailing Address - Phone:405-271-2131
Mailing Address - Fax:405-271-2432
Practice Address - Street 1:1600 N PHILLIPS AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104-4619
Practice Address - Country:US
Practice Address - Phone:405-271-2131
Practice Address - Fax:405-271-2432
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKOK940225100000X
OK1902251S0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports