Provider Demographics
NPI:1891761698
Name:ANDERSON, GARY L (DO)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:L
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 1:3533 SOUTHERN BLVD STE 2250
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-1270
Mailing Address - Country:US
Mailing Address - Phone:937-534-0330
Mailing Address - Fax:937-522-8995
Practice Address - Street 1:3533 SOUTHERN BLVD
Practice Address - Street 2:SUITE 2250
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-1264
Practice Address - Country:US
Practice Address - Phone:937-534-0330
Practice Address - Fax:937-534-0340
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-00-4496A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0883021Medicaid
OHF30440Medicare UPIN
OHAN0718616Medicare ID - Type Unspecified
OH0883021Medicaid