Provider Demographics
NPI:1881630440
Name:ANDERSON, JOHN MICHAEL JEREMY (DO)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MICHAEL JEREMY
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 NW 11TH ST STE 201
Mailing Address - Street 2:
Mailing Address - City:HERMISTON
Mailing Address - State:OR
Mailing Address - Zip Code:97838-6936
Mailing Address - Country:US
Mailing Address - Phone:541-289-4118
Mailing Address - Fax:541-667-3484
Practice Address - Street 1:620 NW 11TH ST # M201
Practice Address - Street 2:
Practice Address - City:HERMISTON
Practice Address - State:OR
Practice Address - Zip Code:97838-6941
Practice Address - Country:US
Practice Address - Phone:541-289-7075
Practice Address - Fax:541-289-1189
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO26732207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR240454Medicaid
ORDO26732OtherMD LICENSE
OR1336264399OtherDME
ORBA7177997OtherDEA
OR240454Medicaid
OR205157724OtherTIN
ORDO26732OtherMD LICENSE
ORH49159Medicare UPIN