Provider Demographics
NPI:1770785966
Name:ANDERSON FOOT & ANKLE CLINIC PC
Entity type:Organization
Organization Name:ANDERSON FOOT & ANKLE CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:D
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:405-360-9338
Mailing Address - Street 1:817 24TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73069-6313
Mailing Address - Country:US
Mailing Address - Phone:405-360-9338
Mailing Address - Fax:405-366-1669
Practice Address - Street 1:817 24TH AVE NW
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73069-6313
Practice Address - Country:US
Practice Address - Phone:405-360-9338
Practice Address - Fax:405-366-1669
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-01
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK190213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200052420AMedicaid
OK1163970001Medicare NSC
OKOKB5264Medicare PIN
OKU57180Medicare UPIN