Healthcare Provider Details

I. General information

NPI: 1881911477
Provider Name (Legal Business Name): D. GORDON ANDERSON, MD., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2010
Last Update Date: 04/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1130 COFFEE RD STE 5B
MODESTO CA
95355-4228
US

IV. Provider business mailing address

1130 COFFEE RD STE 5B
MODESTO CA
95355-4228
US

V. Phone/Fax

Practice location:
  • Phone: 209-529-2710
  • Fax: 209-529-5765
Mailing address:
  • Phone: 209-529-2710
  • Fax: 209-529-5765

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberA020223
License Number StateCA

VIII. Authorized Official

Name: DR. D. GORDON ANDERSON
Title or Position: PRESIDENT
Credential: M.D.
Phone: 209-529-2710