Provider Demographics
NPI:1942405923
Name:ANDERSON, KATHY M (MD)
Entity Type:Individual
Prefix:DR
First Name:KATHY
Middle Name:M
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5119 FOUNTAINBLUE DR
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58503-8893
Mailing Address - Country:US
Mailing Address - Phone:401-952-0293
Mailing Address - Fax:
Practice Address - Street 1:1500 EAST EXCHANGE AVENUE
Practice Address - Street 2:SUITE 201
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-5850
Practice Address - Country:US
Practice Address - Phone:401-952-0293
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-19
Last Update Date:2020-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND11368208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty