Healthcare Provider Details

I. General information

NPI: 1649337635
Provider Name (Legal Business Name): LUIS M ANDERSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/02/2007
Last Update Date: 02/01/2020
Certification Date: 02/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3670 US 1 S STE 300B
SAINT AUGUSTINE FL
32086-6354
US

IV. Provider business mailing address

3670 US 1 S STE 300B
SAINT AUGUSTINE FL
32086-6354
US

V. Phone/Fax

Practice location:
  • Phone: 904-479-9501
  • Fax: 904-217-0524
Mailing address:
  • Phone: 904-479-9501
  • Fax: 904-217-0524

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME0089595
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: