Provider Demographics
NPI:1720174733
Name:ANDERSON, PAUL M (MD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:M
Last Name:ANDERSON
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:PO BOX 378
Mailing Address - Street 2:
Mailing Address - City:VAN BUREN
Mailing Address - State:AR
Mailing Address - Zip Code:72957-0378
Mailing Address - Country:US
Mailing Address - Phone:479-452-2048
Mailing Address - Fax:479-452-2048
Practice Address - Street 1:2010 CHESTNUT
Practice Address - Street 2:SUITE F
Practice Address - City:VAN BUREN
Practice Address - State:AR
Practice Address - Zip Code:72956
Practice Address - Country:US
Practice Address - Phone:479-471-4150
Practice Address - Fax:479-471-4188
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR-1979174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR18155000040OtherDUAL CHOICE
AR50113OtherBCBS
AR18155000040OtherDUAL CHOICE
AR50113Medicare ID - Type Unspecified