Provider Demographics
NPI:1831246719
Name:ANDERSEN, JEREMIAH JOHN (MD)
Entity type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:JOHN
Last Name:ANDERSEN
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 1:5802 WRIGHT DR
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80538-8806
Mailing Address - Country:US
Mailing Address - Phone:970-212-0530
Mailing Address - Fax:
Practice Address - Street 1:5802 WRIGHT DR
Practice Address - Street 2:
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80538-8806
Practice Address - Country:US
Practice Address - Phone:970-212-0530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0056105207ZP0102X
WI50348020207ZP0102X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO57130256Medicaid
CO57130256Medicaid