Provider Demographics
NPI:1891987392
Name:ANDERSON, CARRYN M (MD)
Entity Type:Individual
Prefix:
First Name:CARRYN
Middle Name:M
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CARRYN
Other - Middle Name:M
Other - Last Name:ENSRUDE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:200 HAWKINS DR
Mailing Address - Street 2:01614 PFPW
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52242-1009
Mailing Address - Country:US
Mailing Address - Phone:319-353-8836
Mailing Address - Fax:319-356-1530
Practice Address - Street 1:200 HAWKINS DR
Practice Address - Street 2:01614 PFPW
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52242-1009
Practice Address - Country:US
Practice Address - Phone:319-353-8836
Practice Address - Fax:319-356-1530
Is Sole Proprietor?:No
Enumeration Date:2007-08-17
Last Update Date:2009-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH57.0073462085R0001X
IA378602085R0001X
OH35.0909772085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAI0923087Medicare PIN
IAP00712201Medicare PIN