Provider Demographics
NPI:1215924774
Name:ANDERSON, LARRY SIMON (MD)
Entity type:Individual
Prefix:DR
First Name:LARRY
Middle Name:SIMON
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 1:19020 33RD AVE W
Mailing Address - Street 2:SUITE 210
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98036-4746
Mailing Address - Country:US
Mailing Address - Phone:425-563-1500
Mailing Address - Fax:425-563-1374
Practice Address - Street 1:19020 33RD AVE W
Practice Address - Street 2:SUITE 210
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98036-4746
Practice Address - Country:US
Practice Address - Phone:425-563-1500
Practice Address - Fax:425-563-1374
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2015-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000101192085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA115842OtherLNI PROVIDER ID
WA8197105Medicaid
WAGAB03734Medicare PIN
WA8197105Medicaid
WAG8893181Medicare PIN
WA300085420Medicare PIN
WAA09336Medicare UPIN