Provider Demographics
NPI:1972685394
Name:ANDERSON, VICKI L (MD)
Entity Type:Individual
Prefix:DR
First Name:VICKI
Middle Name:L
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 1:512 SKYLINE BLVD
Mailing Address - Street 2:
Mailing Address - City:CLOQUET
Mailing Address - State:MN
Mailing Address - Zip Code:55720-1199
Mailing Address - Country:US
Mailing Address - Phone:218-879-4641
Mailing Address - Fax:218-879-8904
Practice Address - Street 1:512 SKYLINE BLVD
Practice Address - Street 2:
Practice Address - City:CLOQUET
Practice Address - State:MN
Practice Address - Zip Code:55720-1199
Practice Address - Country:US
Practice Address - Phone:218-879-4641
Practice Address - Fax:218-879-8904
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2019-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN22662207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN550T0ANOtherBLUES & FIRST PLAN
MN0119768OtherMEDICA
MN204287800Medicaid
MN080013821Medicare ID - Type Unspecified
MN550T0ANOtherBLUES & FIRST PLAN