Provider Demographics
NPI:1811074834
Name:ANDERSON, ANTHONY VINCENT (MD)
Entity type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:VINCENT
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 38
Mailing Address - Street 2:
Mailing Address - City:SACATON
Mailing Address - State:AZ
Mailing Address - Zip Code:85147-0001
Mailing Address - Country:US
Mailing Address - Phone:602-528-1200
Mailing Address - Fax:602-528-1255
Practice Address - Street 1:483 W SEED FARM RD
Practice Address - Street 2:
Practice Address - City:SACATON
Practice Address - State:AZ
Practice Address - Zip Code:85147-5000
Practice Address - Country:US
Practice Address - Phone:602-528-1200
Practice Address - Fax:602-528-1255
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-13178207Q00000X
WAMD60435859207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMD60435859OtherWASHINGTON MEDICAL LICENSE
AZ63887OtherARIZONA MEDICAL LICENSE
IDM-13178OtherIDAHO MEDICAL LICENSE