Provider Demographics
NPI:1124082359
Name:ANDERSEN, LUCILLE B (MD)
Entity type:Individual
Prefix:
First Name:LUCILLE
Middle Name:B
Last Name:ANDERSEN
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 1:913 SAN RAMON VALLEY BLVD
Mailing Address - Street 2:SUITE 182
Mailing Address - City:DANVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94526
Mailing Address - Country:US
Mailing Address - Phone:925-263-2499
Mailing Address - Fax:
Practice Address - Street 1:913 SAN RAMON VALLEY BLVD
Practice Address - Street 2:SUITE 182
Practice Address - City:DANVILLE
Practice Address - State:CA
Practice Address - Zip Code:94526
Practice Address - Country:US
Practice Address - Phone:925-263-2499
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-14
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD0426365207X00000X
CAC54414207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1013707600001Medicaid
094344Medicare ID - Type Unspecified
I40602Medicare UPIN