Provider Demographics
NPI:1942220058
Name:ANDERSON, EARL (MD)
Entity type:Individual
Prefix:
First Name:EARL
Middle Name:
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 1:710 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:WAUPACA
Mailing Address - State:WI
Mailing Address - Zip Code:54981-1941
Mailing Address - Country:US
Mailing Address - Phone:920-256-3000
Mailing Address - Fax:715-256-3079
Practice Address - Street 1:710 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:WAUPACA
Practice Address - State:WI
Practice Address - Zip Code:54981-1941
Practice Address - Country:US
Practice Address - Phone:715-258-1160
Practice Address - Fax:715-256-3079
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI26741207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000169010OtherMEDICARE PTAN
WI30834600Medicaid
E50664Medicare UPIN