Provider Demographics
NPI:1770583080
Name:ANDERSON, JESSE III (DPM)
Entity type:Individual
Prefix:DR
First Name:JESSE
Middle Name:
Last Name:ANDERSON
Suffix:III
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401 GODWIN BLVD STE 1
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434-8178
Mailing Address - Country:US
Mailing Address - Phone:757-625-2962
Mailing Address - Fax:757-627-9861
Practice Address - Street 1:2401 GODWIN BLVD STE 1
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-8178
Practice Address - Country:US
Practice Address - Phone:757-625-2962
Practice Address - Fax:757-627-9861
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0103000709213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA62841OtherOPTIMA
VA282441OtherANTHEM
VA0103000709OtherLIC
VA0103000709OtherLIC
T93256Medicare UPIN
VA0103000709OtherLIC