Provider Demographics
NPI:1982679932
Name:ANDERSON, KENNETH E JR (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:E
Last Name:ANDERSON
Suffix:JR
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:PO BOX 837
Mailing Address - Street 2:
Mailing Address - City:HOWE
Mailing Address - State:TX
Mailing Address - Zip Code:75459-0837
Mailing Address - Country:US
Mailing Address - Phone:903-893-6000
Mailing Address - Fax:903-868-1802
Practice Address - Street 1:500 E PEYTON ST
Practice Address - Street 2:
Practice Address - City:SHERMAN
Practice Address - State:TX
Practice Address - Zip Code:75090-0200
Practice Address - Country:US
Practice Address - Phone:903-893-6000
Practice Address - Fax:903-868-1802
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-22
Last Update Date:2019-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL6764174400000X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX161185701Medicaid
OK200019230AMedicaid
0044STOtherBCBS
TX8B1207OtherBCBS PROV #
8F23578Medicare PIN
TX8B1207Medicare PIN
H91781Medicare UPIN