Provider Demographics
NPI:1316947484
Name:ANDERSON, JOHN DAVID (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:DAVID
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 1:2704 N OAK ST
Mailing Address - Street 2:BLDG O
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-1744
Mailing Address - Country:US
Mailing Address - Phone:229-247-2350
Mailing Address - Fax:229-247-6826
Practice Address - Street 1:2704 N OAK ST
Practice Address - Street 2:BLDG O
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1744
Practice Address - Country:US
Practice Address - Phone:229-247-2350
Practice Address - Fax:229-247-6826
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-29
Last Update Date:2009-12-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GAGA021630207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00229919CMedicaid
11D0265529OtherCLIA
FL2641658-01Medicaid
GA00229919CMedicaid