Provider Demographics
NPI:1841294774
Name:ANDERSON, DOUGLAS EDWARD (MD)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:EDWARD
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:201 NW MEDICAL LOOP STE 190
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471-8835
Mailing Address - Country:US
Mailing Address - Phone:541-677-4319
Mailing Address - Fax:541-677-2294
Practice Address - Street 1:2801 NW MERCY DR STE 300
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-2348
Practice Address - Country:US
Practice Address - Phone:541-677-1555
Practice Address - Fax:541-677-2113
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2020-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD192562207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G369041Medicaid
CAA46859Medicare UPIN
CA00G369040Medicare ID - Type Unspecified