Provider Demographics
NPI:1245527969
Name:ANDERSON, JACK D (DO)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:D
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1080
Mailing Address - Street 2:
Mailing Address - City:BURKESVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42717-1080
Mailing Address - Country:US
Mailing Address - Phone:270-864-1472
Mailing Address - Fax:270-864-1693
Practice Address - Street 1:1515 EDMONTON RD
Practice Address - Street 2:
Practice Address - City:TOMPKINSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42167-9402
Practice Address - Country:US
Practice Address - Phone:270-487-9272
Practice Address - Fax:270-487-6242
Is Sole Proprietor?:No
Enumeration Date:2011-07-01
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY03464207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100197370Medicaid
KY7100197370Medicaid