Provider Demographics
NPI:1811095508
Name:ANDERSON, MICHAEL LESLIE (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:LESLIE
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 1:4741 BURR OAK ST
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55122-3321
Mailing Address - Country:US
Mailing Address - Phone:651-895-1171
Mailing Address - Fax:
Practice Address - Street 1:1 VETERANS DRIVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55417-9969
Practice Address - Country:US
Practice Address - Phone:612-467-1100
Practice Address - Fax:612-467-1913
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN24939207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
D81832Medicare UPIN