Provider Demographics
NPI:1891801981
Name:ANDERSEN, JOHN MARTIN (MD)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:MARTIN
Last Name:ANDERSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:933 N CHARLOTTE STREET
Mailing Address - Street 2:3-A
Mailing Address - City:POTTS
Mailing Address - State:PA
Mailing Address - Zip Code:19464-3974
Mailing Address - Country:US
Mailing Address - Phone:610-323-9052
Mailing Address - Fax:610-323-3085
Practice Address - Street 1:933 N CHARLOTTE STREET
Practice Address - Street 2:3-A
Practice Address - City:POTTS
Practice Address - State:PA
Practice Address - Zip Code:19464-3974
Practice Address - Country:US
Practice Address - Phone:610-323-9052
Practice Address - Fax:610-323-3085
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2011-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD 039149E207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA018149OtherAETNA HMO
000506727OtherCAPITAL BLUE CROSS
000506727OtherINDEPENDENCE BLUE CROSS
232925465OtherBERKSHIRE HEALTH PLANS
000506727OtherBLUE CROSS BLUE SHIELD
232925465OtherCOVENTRY HEALTHCARE OF DE
000506727OtherHIGHMARK BLUE CROSS
PA0011067390001Medicaid
PA0109636001OtherKHPE/IBC
1025953OtherKEYSTONEMERCY HEALTH PLAN
232925465OtherBLUE CROSS OF DE
PAAN506727Medicare ID - Type Unspecified
000506727OtherINDEPENDENCE BLUE CROSS