Healthcare Provider Details

I. General information

NPI: 1336609916
Provider Name (Legal Business Name): ANDREW DYLAN ANDERSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2019
Last Update Date: 05/12/2023
Certification Date: 05/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 JOHNSON FERRY RD
ATLANTA GA
30342-1606
US

IV. Provider business mailing address

1000 JOHNSON FERRY RD
ATLANTA GA
30342-1606
US

V. Phone/Fax

Practice location:
  • Phone: 404-851-8917
  • Fax: 404-303-3636
Mailing address:
  • Phone: 404-851-8917
  • Fax: 404-303-3636

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number94965
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: