Provider Demographics
NPI:1295155778
Name:ANDERSON, ALEX (MD)
Entity type:Individual
Prefix:
First Name:ALEX
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1747 IMPERIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605-5362
Mailing Address - Country:US
Mailing Address - Phone:337-721-7236
Mailing Address - Fax:337-721-7237
Practice Address - Street 1:1747 IMPERIAL BLVD
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-5362
Practice Address - Country:US
Practice Address - Phone:337-721-7236
Practice Address - Fax:337-721-7237
Is Sole Proprietor?:No
Enumeration Date:2014-04-23
Last Update Date:2019-01-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA208128207QS0010X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine