Provider Demographics
NPI:1154373454
Name:ANDERSON, GARY D (MD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:D
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 1:3524 TORRANCE BLVD
Mailing Address - Street 2:STE 102
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90503-4821
Mailing Address - Country:US
Mailing Address - Phone:310-540-1334
Mailing Address - Fax:310-540-7615
Practice Address - Street 1:3524 TORRANCE BLVD
Practice Address - Street 2:STE 102
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-4821
Practice Address - Country:US
Practice Address - Phone:310-540-1334
Practice Address - Fax:310-540-7615
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2011-12-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG52512208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
A52279Medicare UPIN
CAWG52512MMedicare UPIN
CAWG52512KMedicare ID - Type UnspecifiedMEDICARE PPIN