Healthcare Provider Details

I. General information

NPI: 1770708554
Provider Name (Legal Business Name): SAMUEL DEE ANDERSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2007
Last Update Date: 04/29/2024
Certification Date: 04/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2420 CAMINO RAMON STE. 270
SAN RAMON CA
94583-4385
US

IV. Provider business mailing address

PO BOX 603484
CHARLOTTE NC
28260-3484
US

V. Phone/Fax

Practice location:
  • Phone: 925-543-0141
  • Fax: 925-543-0145
Mailing address:
  • Phone: 803-765-1838
  • Fax: 803-765-1732

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberA98380
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number232721
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA98380
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number232721
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: