Provider Demographics
NPI:1013058254
Name:ANDERSON, MICHAEL LUTHER (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:LUTHER
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5465 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SYLVANIA
Mailing Address - State:OH
Mailing Address - Zip Code:43560-2155
Mailing Address - Country:US
Mailing Address - Phone:419-885-8800
Mailing Address - Fax:419-885-8600
Practice Address - Street 1:5465 MAIN ST
Practice Address - Street 2:
Practice Address - City:SYLVANIA
Practice Address - State:OH
Practice Address - Zip Code:43560-2155
Practice Address - Country:US
Practice Address - Phone:419-885-8800
Practice Address - Fax:419-885-8600
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH887442084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4301085123OtherPHYSICIAN LICENSE
OH88744OtherDR OF MEDICINE