Provider Demographics
NPI:1861522070
Name:ANDERSON, RICHARD LANE (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:LANE
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2701 W ALAMEDA AVE
Mailing Address - Street 2:200
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91505-4402
Mailing Address - Country:US
Mailing Address - Phone:818-843-4192
Mailing Address - Fax:818-955-8598
Practice Address - Street 1:2701 W ALAMEDA AVE
Practice Address - Street 2:200
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-4402
Practice Address - Country:US
Practice Address - Phone:818-843-4192
Practice Address - Fax:818-955-8598
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG037464207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW5853Medicare ID - Type Unspecified
CAA91897Medicare UPIN
CAWG37464AMedicare ID - Type Unspecified