Healthcare Provider Details

I. General information

NPI: 1083929137
Provider Name (Legal Business Name): WILLIAM CHARLES ANDERSON D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2010
Last Update Date: 06/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3380 DALEY CENTER DR APT#1905
SAN DIEGO CA
92123
US

IV. Provider business mailing address

3380 DALEY CENTER DR APT#1905
SAN DIEGO CA
92123-4640
US

V. Phone/Fax

Practice location:
  • Phone: 716-785-3152
  • Fax:
Mailing address:
  • Phone: 716-785-3152
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number02003973A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: