Provider Demographics
NPI:1669410213
Name:GANDERSON, ALAN P (MD)
Entity type:Individual
Prefix:
First Name:ALAN
Middle Name:P
Last Name:GANDERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1112 WINDSOR RD
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23451-3752
Mailing Address - Country:US
Mailing Address - Phone:757-425-1114
Mailing Address - Fax:757-963-5585
Practice Address - Street 1:1101 FIRST COLONIAL RD
Practice Address - Street 2:SUITE 300
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-2409
Practice Address - Country:US
Practice Address - Phone:757-481-2127
Practice Address - Fax:757-481-7138
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2016-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101019855207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010119341Medicaid
VA00W184T10Medicare ID - Type Unspecified
VA010119341Medicaid