Provider Demographics
NPI:1124128509
Name:ANDERSON, MARK JAMES (DC)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:JAMES
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 100
Mailing Address - Street 2:
Mailing Address - City:HORTONVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:54944
Mailing Address - Country:US
Mailing Address - Phone:920-779-4554
Mailing Address - Fax:920-779-0444
Practice Address - Street 1:216 WEST MAIN ST
Practice Address - Street 2:
Practice Address - City:HORTONVILLE
Practice Address - State:WI
Practice Address - Zip Code:54944
Practice Address - Country:US
Practice Address - Phone:920-779-4554
Practice Address - Fax:920-779-0444
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3779111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38936900Medicaid
WI38936900Medicaid
U86903Medicare UPIN