Provider Demographics
NPI:1356720387
Name:ANDERSON, KEVIN (MD, PHD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
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 1:330 BROOKLINE AVE
Mailing Address - Street 2:DEPARTMENT OF PATHOLOGY
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-5400
Mailing Address - Country:US
Mailing Address - Phone:617-667-4344
Mailing Address - Fax:
Practice Address - Street 1:1 HAMPTON RD UNIT 208
Practice Address - Street 2:
Practice Address - City:EXETER
Practice Address - State:NH
Practice Address - Zip Code:03833-4849
Practice Address - Country:US
Practice Address - Phone:866-484-3522
Practice Address - Fax:603-778-1602
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-22
Last Update Date:2018-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA269567207ZP0102X
MA256001390200000X
NH18713207ZP0102X
MEMD22122207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program