Provider Demographics
NPI:1356908552
Name:ANDERSON, JOHN EDWARD (DO)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:EDWARD
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 1:2222 CHERRY ST STE 2000
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43608-2673
Mailing Address - Country:US
Mailing Address - Phone:419-251-2061
Mailing Address - Fax:
Practice Address - Street 1:2222 CHERRY ST STE 2000
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43608-2673
Practice Address - Country:US
Practice Address - Phone:419-251-2061
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-22
Last Update Date:2024-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.0168302080S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080S0010XAllopathic & Osteopathic PhysiciansPediatricsSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0031377Medicaid