Provider Demographics
NPI:1699701466
Name:ANDERSON, DOUGLAS JEFFERSON (M D)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:JEFFERSON
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2621 TOUPS TRL
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32780-6754
Mailing Address - Country:US
Mailing Address - Phone:321-383-8484
Mailing Address - Fax:
Practice Address - Street 1:500 N WASHINGTON AVE
Practice Address - Street 2:SUITE 208
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32796-2759
Practice Address - Country:US
Practice Address - Phone:321-269-3808
Practice Address - Fax:321-267-9156
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0052042207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
07443Medicare ID - Type UnspecifiedMEDICARE NUMBER
C47306Medicare UPIN