Provider Demographics
NPI:1740249580
Name:ANDERSON, JOHN FREDERICK (DO)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:FREDERICK
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:PO BOX 30797
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06150-0797
Mailing Address - Country:US
Mailing Address - Phone:631-547-6392
Mailing Address - Fax:
Practice Address - Street 1:270 PARK AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-2787
Practice Address - Country:US
Practice Address - Phone:631-351-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY234530207RP1001X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02632511Medicaid
NY7051R1Medicare ID - Type Unspecified
NYP00245454Medicare PIN
I25433Medicare UPIN