Healthcare Provider Details

I. General information

NPI: 1588862114
Provider Name (Legal Business Name): COREY D ANDERSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2007
Last Update Date: 05/22/2026
Certification Date: 05/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 S CREASY LN
LAFAYETTE IN
47905-4972
US

IV. Provider business mailing address

PO BOX 78106
DETROIT MI
48278-1008
US

V. Phone/Fax

Practice location:
  • Phone: 765-502-4917
  • Fax: 765-502-4023
Mailing address:
  • Phone: 317-528-4800
  • Fax: 317-865-1479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number0101260667
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberME109122
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberU4391
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number3049-320
License Number StateWI
# 5
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number35.098567
License Number StateOH
# 6
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberC192246
License Number StateCA
# 7
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number2024049040
License Number StateMO
# 8
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberR8025
License Number StateIA
# 9
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberMD217005
License Number StateOR
# 10
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number01076345A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: