Provider Demographics
NPI:1417995291
Name:ANDERSON, WILLIAM DOUGLAS (MD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:DOUGLAS
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:WILLIAM
Other - Middle Name:
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:861 SW 78TH AVE
Mailing Address - Street 2:SUITE 100B
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33324-3229
Mailing Address - Country:US
Mailing Address - Phone:954-693-0000
Mailing Address - Fax:954-693-0005
Practice Address - Street 1:712 N WOOD ST
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:GILMER
Practice Address - State:TX
Practice Address - Zip Code:75644-1751
Practice Address - Country:US
Practice Address - Phone:903-841-7100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-03
Last Update Date:2010-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH3365207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXC12818Medicare UPIN
TX8L24373Medicare PIN