Healthcare Provider Details

I. General information

NPI: 1619213378
Provider Name (Legal Business Name): JUDITH A ANDERSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/27/2012
Last Update Date: 10/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 EAST VILLANOW STREET
LA FAYETTE GA
30728
US

IV. Provider business mailing address

611 EAST VILLANOW STREET
LA FAYETTE GA
30728
US

V. Phone/Fax

Practice location:
  • Phone: 706-638-1606
  • Fax: 706-638-9907
Mailing address:
  • Phone: 706-638-1606
  • Fax: 706-638-9907

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number26779
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number074892
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: