Provider Demographics
NPI:1497833164
Name:ANDERSON, NICOLE A (MD)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:A
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:223 NORTH VAN DIEN AVENUE
Mailing Address - Street 2:THE VALLEY HOSPITAL
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07450
Mailing Address - Country:US
Mailing Address - Phone:201-447-8388
Mailing Address - Fax:201-447-8616
Practice Address - Street 1:223 NORTH VAN DIEN AVENUE
Practice Address - Street 2:THE VALLEY HOSPITAL
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450
Practice Address - Country:US
Practice Address - Phone:201-447-8388
Practice Address - Fax:201-447-8616
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2014-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA926322080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A926320Medicaid
CA00A926320Medicaid
00A926320Medicare ID - Type Unspecified