Healthcare Provider Details

I. General information

NPI: 1104047695
Provider Name (Legal Business Name): JAMES L. ANDERSEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 11/14/2024
Certification Date: 11/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 CRYSTAL BEACH ROAD
EAGLE LAKE FL
33839
US

IV. Provider business mailing address

805 CRYSTAL BEACH ROAD
EAGLE LAKE FL
33839
US

V. Phone/Fax

Practice location:
  • Phone: 863-287-3485
  • Fax: 863-683-9180
Mailing address:
  • Phone: 863-287-3485
  • Fax: 863-683-9180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083A0300X
TaxonomyAddiction Medicine (Preventive Medicine) Physician
License NumberME0024931
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License NumberME0024931
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: