Provider Demographics
NPI:1548338551
Name:ANDERSON, DAVID JOHN (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:JOHN
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:30 5TH ST
Mailing Address - Street 2:SUITE 150
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94952-3042
Mailing Address - Country:US
Mailing Address - Phone:707-763-9122
Mailing Address - Fax:707-782-9074
Practice Address - Street 1:30 5TH ST
Practice Address - Street 2:SUITE 150
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952-3042
Practice Address - Country:US
Practice Address - Phone:707-763-9122
Practice Address - Fax:707-782-9074
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG369492084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
BA6709008OtherDEA REGISTRATION
CA00G369490Medicare ID - Type Unspecified
A46878Medicare UPIN