Provider Demographics
NPI:1134124191
Name:ANDERSON, BRIAN D (DO)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:D
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:865 LINCOLN RD
Mailing Address - Street 2:STE L10
Mailing Address - City:BETTENDORF
Mailing Address - State:IA
Mailing Address - Zip Code:52722-4159
Mailing Address - Country:US
Mailing Address - Phone:563-355-9191
Mailing Address - Fax:563-355-3419
Practice Address - Street 1:2526 41ST ST
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-5016
Practice Address - Country:US
Practice Address - Phone:309-792-6540
Practice Address - Fax:309-764-9326
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2023-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-098957207P00000X
IL036098957207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01G3OtherJOHN DEERE HEALTH PLAN
479890019OtherDMERC
IA90767OtherWELLMARK BC/BS
IL036098957Medicaid
20212OtherIOWA HEALTH SOLUTIONS
048462OtherHEALTH ALLIANCE
048462OtherHEALTH ALLIANCE
ILL95026Medicare PIN
G39747Medicare UPIN