Provider Demographics
NPI:1194794727
Name:ANDERSON, JOHN JAMES (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:JAMES
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 1:7008 TRYALTAN LN
Mailing Address - Street 2:
Mailing Address - City:CANFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44406-9422
Mailing Address - Country:US
Mailing Address - Phone:330-533-2836
Mailing Address - Fax:
Practice Address - Street 1:500 GYPSY LN
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44504-1315
Practice Address - Country:US
Practice Address - Phone:330-884-3957
Practice Address - Fax:330-884-5684
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH32-02-1295208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0680884Medicaid
OH35-02-1295OtherMEDICAL LICENSE
OHH26216Medicare UPIN