Healthcare Provider Details

I. General information

NPI: 1386059657
Provider Name (Legal Business Name): STUART T ANDERSON, MD, A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2014
Last Update Date: 04/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

604 VIA PROMONTORIO
SAN CLEMENTE CA
92672-2458
US

IV. Provider business mailing address

604 VIA PROMONTORIO
SAN CLEMENTE CA
92672-2458
US

V. Phone/Fax

Practice location:
  • Phone: 949-248-9750
  • Fax:
Mailing address:
  • Phone: 949-248-9750
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberG50002
License Number StateCA

VIII. Authorized Official

Name: DR. STUART T ANDERSON
Title or Position: PRESIDENT/CEO
Credential:
Phone: 949-248-9750