Provider Demographics
NPI:1922029271
Name:ANDERS, REUBEN MAKALA (MD)
Entity Type:Individual
Prefix:
First Name:REUBEN
Middle Name:MAKALA
Last Name:ANDERS
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 1:461 7TH ST W STE 3
Mailing Address - Street 2:
Mailing Address - City:SONOMA
Mailing Address - State:CA
Mailing Address - Zip Code:95476-5976
Mailing Address - Country:US
Mailing Address - Phone:707-938-1423
Mailing Address - Fax:
Practice Address - Street 1:461 7TH ST W STE 3
Practice Address - Street 2:
Practice Address - City:SONOMA
Practice Address - State:CA
Practice Address - Zip Code:95476-5976
Practice Address - Country:US
Practice Address - Phone:707-938-1423
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00046746207N00000X
HIMD-13554207N00000X
CAA79025207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8463564Medicaid
CA00A790250OtherMEDICARE PTAN
WA7590826OtherAETNA#
WA3298ANOtherBLUE SHIELD #
CA00A790250OtherMEDICARE PTAN
WA8860995Medicare ID - Type Unspecified