Provider Demographics
NPI:1952461584
Name:ANDERSON, MICHAEL WARREN (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:WARREN
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 1:63 W UNDERWOOD ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-1118
Mailing Address - Country:US
Mailing Address - Phone:407-872-1110
Mailing Address - Fax:407-839-4869
Practice Address - Street 1:63 W UNDERWOOD ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-1118
Practice Address - Country:US
Practice Address - Phone:407-872-1110
Practice Address - Fax:407-839-4869
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME46655174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
59971ZMedicare ID - Type Unspecified
FLD65222Medicare UPIN