Provider Demographics
NPI:1326550096
Name:LAWRENCE D ANDERSON MD ESTATE
Entity type:Organization
Organization Name:LAWRENCE D ANDERSON MD ESTATE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PERSONAL REPRESENTATIVE
Authorized Official - Prefix:MR
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:B
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-344-7944
Mailing Address - Street 1:8955 W HACKAMORE DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709
Mailing Address - Country:US
Mailing Address - Phone:208-344-7944
Mailing Address - Fax:208-343-4676
Practice Address - Street 1:8955 W HACKAMORE DR
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709
Practice Address - Country:US
Practice Address - Phone:208-344-7944
Practice Address - Fax:208-343-4676
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-02
Last Update Date:2019-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1942316054Medicaid
ID1326302548Medicaid