Provider Demographics
NPI:1972659225
Name:ANDERSON, AXEL WILLIAM IV (MD)
Entity Type:Individual
Prefix:DR
First Name:AXEL
Middle Name:WILLIAM
Last Name:ANDERSON
Suffix:IV
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 1:2900 17TH ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:SAINT CLOUD
Mailing Address - State:FL
Mailing Address - Zip Code:34769-6098
Mailing Address - Country:US
Mailing Address - Phone:407-891-2951
Mailing Address - Fax:407-891-2952
Practice Address - Street 1:2900 17TH ST
Practice Address - Street 2:SUITE 2
Practice Address - City:SAINT CLOUD
Practice Address - State:FL
Practice Address - Zip Code:34769-6098
Practice Address - Country:US
Practice Address - Phone:407-891-2951
Practice Address - Fax:407-891-2952
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2013-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME43875208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG08749OtherUPIN
FL47682ZOtherMEDICARE