Provider Demographics
NPI:1023011988
Name:ANDERSON, BRIAN JAY (DC)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:JAY
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3950 SUNSET DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76904-5622
Mailing Address - Country:US
Mailing Address - Phone:325-949-1600
Mailing Address - Fax:325-944-3754
Practice Address - Street 1:3950 SUNSET DR
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76904-5622
Practice Address - Country:US
Practice Address - Phone:325-949-1600
Practice Address - Fax:325-944-3754
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2012-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4939111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8F5111OtherBLUE CROSS/BLUE SHIELD
TX001442501Medicaid
TX8710B0Medicare PIN
TX001442501Medicaid