Provider Demographics
NPI:1902834914
Name:ANDERSON, WAYNE JULIUS (MD)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:JULIUS
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 1:550 E COLORADO BLVD
Mailing Address - Street 2:
Mailing Address - City:SPEARFISH
Mailing Address - State:SD
Mailing Address - Zip Code:57783-2776
Mailing Address - Country:US
Mailing Address - Phone:605-642-2030
Mailing Address - Fax:
Practice Address - Street 1:550 E COLORADO BLVD
Practice Address - Street 2:
Practice Address - City:SPEARFISH
Practice Address - State:SD
Practice Address - Zip Code:57783-2776
Practice Address - Country:US
Practice Address - Phone:605-642-2030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1344207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD0007482OtherWELLMARK BCBS
SD1344OtherDAKOTA CARE
SD0007482OtherWELLMARK BCBS
D25137Medicare UPIN