Provider Demographics
NPI:1003061078
Name:R MAKALA ANDERS MD MEDICAL CORPORATION
Entity type:Organization
Organization Name:R MAKALA ANDERS MD MEDICAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:REUBEN
Authorized Official - Middle Name:MAKALA
Authorized Official - Last Name:ANDERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:707-938-1423
Mailing Address - Street 1:461 7TH ST W STE 3
Mailing Address - Street 2:
Mailing Address - City:SONOMA
Mailing Address - State:CA
Mailing Address - Zip Code:95476-5976
Mailing Address - Country:US
Mailing Address - Phone:707-938-1423
Mailing Address - Fax:
Practice Address - Street 1:461 7TH ST W STE 3
Practice Address - Street 2:
Practice Address - City:SONOMA
Practice Address - State:CA
Practice Address - Zip Code:95476-5976
Practice Address - Country:US
Practice Address - Phone:707-938-1423
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-18
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA79025207ND0101X, 207ND0900X, 207NS0135X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Single Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABI781OtherMEDICARE PTAN
CA00A790251OtherMEDICARE PTAN
CABI781OtherMEDICARE PTAN