Provider Demographics
NPI:1801825278
Name:ANDERSON, JULIE (MD)
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3290 42ND AVE S
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56301
Mailing Address - Country:US
Mailing Address - Phone:320-227-5000
Mailing Address - Fax:320-227-5025
Practice Address - Street 1:3290 42ND AVE S
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301
Practice Address - Country:US
Practice Address - Phone:320-227-5000
Practice Address - Fax:320-227-5025
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN43593207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN050915900Medicaid
MNH52436Medicare UPIN
MN080013249Medicare PIN