Healthcare Provider Details

I. General information

NPI: 1801094578
Provider Name (Legal Business Name): MARCUS WALTER ANDERSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/04/2007
Last Update Date: 02/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 HEALTH PARK BLVD
ST AUGUSTINE FL
32086-5784
US

IV. Provider business mailing address

400 HEALTH PARK BLVD
ST AUGUSTINE FL
32086-5784
US

V. Phone/Fax

Practice location:
  • Phone: 904-819-4565
  • Fax: 904-819-4999
Mailing address:
  • Phone: 904-819-4040
  • Fax: 904-819-4041

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberTRN10998
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2084F0202X
TaxonomyForensic Psychiatry Physician
License NumberME105840
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: