Provider Demographics
NPI:1194792671
Name:ANDERSON, KENNETH CARL (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:CARL
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:264 WESTON RD
Mailing Address - Street 2:
Mailing Address - City:WELLESLEY
Mailing Address - State:MA
Mailing Address - Zip Code:02482-4565
Mailing Address - Country:US
Mailing Address - Phone:781-537-6209
Mailing Address - Fax:617-632-2140
Practice Address - Street 1:440 BINNEY ST
Practice Address - Street 2:DANA FARBER CANCER INSTITUTE
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115
Practice Address - Country:US
Practice Address - Phone:617-632-2144
Practice Address - Fax:617-632-2140
Is Sole Proprietor?:No
Enumeration Date:2006-03-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA45550207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
045550OtherTUFTS
2060918OtherAETNA
3004142OtherUNITED HEALTHCARE
B74115DFOtherHPGC DFCI ONLY
MA6190197Medicaid
8941135OtherCIGNA
40652OtherFALCON COMMUNITY HEALTH
B74115Medicare UPIN
J01068Medicare ID - Type Unspecified