Healthcare Provider Details

I. General information

NPI: 1902338585
Provider Name (Legal Business Name): SCOTT JEFFREY ANDERSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2017
Last Update Date: 06/07/2023
Certification Date: 06/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4234 RIVERWALK PKWY STE 230
RIVERSIDE CA
92505-3312
US

IV. Provider business mailing address

4234 RIVERWALK PKWY STE 230
RIVERSIDE CA
92505-3312
US

V. Phone/Fax

Practice location:
  • Phone: 951-781-3672
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberA164327
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberA164327
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: