Provider Demographics
NPI:1982846416
Name:ANDERSON, MICHAEL JAMES (IDMT)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:JAMES
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 LUKE AVE
Mailing Address - Street 2:AFMSA/SG3P
Mailing Address - City:BOLLING AFB
Mailing Address - State:DC
Mailing Address - Zip Code:20032
Mailing Address - Country:US
Mailing Address - Phone:202-767-4340
Mailing Address - Fax:202-767-5302
Practice Address - Street 1:110 LUKE AVE
Practice Address - Street 2:AFMSA/SG3P
Practice Address - City:BOLLING AFB
Practice Address - State:DC
Practice Address - Zip Code:20032
Practice Address - Country:US
Practice Address - Phone:202-767-4340
Practice Address - Fax:202-767-5302
Is Sole Proprietor?:No
Enumeration Date:2009-03-30
Last Update Date:2009-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians