Provider Demographics
NPI:1952495582
Name:ANDERSON, RODNEY (MD)
Entity Type:Individual
Prefix:
First Name:RODNEY
Middle Name:
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 1:379 NORTH 500 WEST
Mailing Address - Street 2:SUITE 1A
Mailing Address - City:VERNAL
Mailing Address - State:UT
Mailing Address - Zip Code:84078
Mailing Address - Country:US
Mailing Address - Phone:435-789-1165
Mailing Address - Fax:435-789-1169
Practice Address - Street 1:379 NORTH 500 WEST
Practice Address - Street 2:SUITE 1A
Practice Address - City:VERNAL
Practice Address - State:UT
Practice Address - Zip Code:84078
Practice Address - Country:US
Practice Address - Phone:435-789-1165
Practice Address - Fax:435-789-1169
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2010-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT91184302-1205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTE78858Medicare UPIN
UT005549201Medicare ID - Type UnspecifiedMEDICARE