Provider Demographics
NPI:1548723356
Name:ANDERSON, ANTHONY ALAN
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:ALAN
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15508 WILLET CT
Mailing Address - Street 2:
Mailing Address - City:MASCOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:34753-9102
Mailing Address - Country:US
Mailing Address - Phone:523-460-6093
Mailing Address - Fax:352-366-0230
Practice Address - Street 1:55 BLUFF LAKE RD
Practice Address - Street 2:
Practice Address - City:MASCOTTE
Practice Address - State:FL
Practice Address - Zip Code:34753-9536
Practice Address - Country:US
Practice Address - Phone:352-460-6093
Practice Address - Fax:352-366-0230
Is Sole Proprietor?:No
Enumeration Date:2019-04-09
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL022905700171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022905700Medicaid