Provider Demographics
NPI:1861494866
Name:ANDERSON, MARK ALLO (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALLO
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 1:40 CAMPO RD
Mailing Address - Street 2:
Mailing Address - City:TIJERAS
Mailing Address - State:NM
Mailing Address - Zip Code:87059-7615
Mailing Address - Country:US
Mailing Address - Phone:505-610-5421
Mailing Address - Fax:
Practice Address - Street 1:40 CAMPO RD
Practice Address - Street 2:
Practice Address - City:TIJERAS
Practice Address - State:NM
Practice Address - Zip Code:87059-7615
Practice Address - Country:US
Practice Address - Phone:505-610-5421
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2007-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301078206207Q00000X
WI45131-020207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine