Provider Demographics
NPI:1851448476
Name:ANDERSON, WILLIE THOMAS III (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIE
Middle Name:THOMAS
Last Name:ANDERSON
Suffix:III
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 1:1021 W OAKLAND AVE STE 310
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-2192
Mailing Address - Country:US
Mailing Address - Phone:423-302-6565
Mailing Address - Fax:
Practice Address - Street 1:378 MARKETPLACE BLVD STE 10C
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-2361
Practice Address - Country:US
Practice Address - Phone:423-431-4946
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD00000392112084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN332756Medicaid
TNMD0000039211OtherSTATE MEDICAL LICENSE
TNBA6322426OtherDEA NUMBER
BA6322426OtherDEA NUMBER
TN332756Medicaid