Provider Demographics
NPI:1184607921
Name:ANDERSON, JOHN (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JOHN
Other - Middle Name:
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2315 STOCKTON BLVD
Mailing Address - Street 2:DEPARTMENT OF SURGERY
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95817-2201
Mailing Address - Country:US
Mailing Address - Phone:916-734-7210
Mailing Address - Fax:916-734-7755
Practice Address - Street 1:2315 STOCKTON BLVD
Practice Address - Street 2:DEPARTMENT OF SURGERY
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817-2201
Practice Address - Country:US
Practice Address - Phone:916-734-7210
Practice Address - Fax:916-734-7755
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00G6624202086S0127X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
00G662420OtherMEDI-CAL
00G662420OtherMEDI-CAL
00G662420Medicare ID - Type Unspecified