Provider Demographics
NPI:1174736953
Name:ANDERSON, MARK ARTHUR (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ARTHUR
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 1:333 O'CONNOR DR
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128
Mailing Address - Country:US
Mailing Address - Phone:408-297-3484
Mailing Address - Fax:408-292-6481
Practice Address - Street 1:333 O'CONNOR DR
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128
Practice Address - Country:US
Practice Address - Phone:408-297-3484
Practice Address - Fax:408-292-6481
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2013-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG34266174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G342660Medicare PIN
CAA45854Medicare UPIN