Provider Demographics
NPI:1861033540
Name:ANDERSON, ED WILLIAM JR
Entity Type:Individual
Prefix:
First Name:ED
Middle Name:WILLIAM
Last Name:ANDERSON
Suffix:JR
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 1:401 LINDEN AVE
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434-5827
Mailing Address - Country:US
Mailing Address - Phone:757-749-5579
Mailing Address - Fax:
Practice Address - Street 1:401 LINDEN AVE
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-5827
Practice Address - Country:US
Practice Address - Phone:757-749-5579
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-03
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2705128261171WH0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171WH0202XOther Service ProvidersContractorHome ModificationsGroup - Single Specialty