Provider Demographics
NPI:1144321746
Name:ANDERSON, DALE JOHNSON (MD)
Entity type:Individual
Prefix:DR
First Name:DALE
Middle Name:JOHNSON
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:6365 CLAYTON ROAD
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63117
Mailing Address - Country:US
Mailing Address - Phone:314-645-1567
Mailing Address - Fax:314-725-4449
Practice Address - Street 1:6365 CLAYTON ROAD
Practice Address - Street 2:
Practice Address - City:ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63117
Practice Address - Country:US
Practice Address - Phone:314-645-1567
Practice Address - Fax:314-725-4449
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR2E002084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
1521222OtherUNITED BEHAVIORAL HEALTH
MO25961OtherBLUE CROSS BLUE SHIELD
132483OtherHEALTHLINK
B18373OtherMERCY HEALTH PLANS
007924000OtherMAGELLAN
012043OtherVALUEOPTIONS
1521222OtherUNITED HEALTH CARE
33326OtherIBEW