Provider Demographics
NPI:1205974136
Name:ANDERSON, DAVID RAY (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:RAY
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 2410
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83403-2410
Mailing Address - Country:US
Mailing Address - Phone:208-529-3937
Mailing Address - Fax:208-524-4380
Practice Address - Street 1:530 S HOLMES
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83403-2410
Practice Address - Country:US
Practice Address - Phone:208-529-3937
Practice Address - Fax:208-524-4380
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM3793207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
1371224Medicare ID - Type Unspecified
E07053Medicare UPIN