Provider Demographics
NPI:1730599598
Name:ANDERSEN, DOUGLAS KEN (DO)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:KEN
Last Name:ANDERSEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:10109 E. 79TH STREET
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133
Mailing Address - Country:US
Mailing Address - Phone:918-286-5000
Mailing Address - Fax:918-249-7514
Practice Address - Street 1:777 HOSPITAL WAY
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-5175
Practice Address - Country:US
Practice Address - Phone:208-239-1720
Practice Address - Fax:208-239-1726
Is Sole Proprietor?:No
Enumeration Date:2014-05-02
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6352207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine