Provider Demographics
NPI:1104807692
Name:ANDERSON, DANIEL KENT (MD)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:KENT
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 1:210 4TH AVE
Mailing Address - Street 2:MAB 3RD FLOOR
Mailing Address - City:GRINNELL
Mailing Address - State:IA
Mailing Address - Zip Code:50112-1898
Mailing Address - Country:US
Mailing Address - Phone:641-236-2382
Mailing Address - Fax:641-236-2907
Practice Address - Street 1:210 4TH AVE
Practice Address - Street 2:MAB 3RD FLOOR
Practice Address - City:GRINNELL
Practice Address - State:IA
Practice Address - Zip Code:50112-1898
Practice Address - Country:US
Practice Address - Phone:641-236-2382
Practice Address - Fax:641-236-2907
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA27178207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1057802Medicaid
IA20762Medicare ID - Type Unspecified
IAE08067Medicare UPIN