Healthcare Provider Details

I. General information

NPI: 1649298381
Provider Name (Legal Business Name): BRAD C ANDERSON DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 04/06/2022
Certification Date: 04/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 32ND AVE S
FARGO ND
58103-5800
US

IV. Provider business mailing address

PO BOX 2010
FARGO ND
58122-0605
US

V. Phone/Fax

Practice location:
  • Phone: 701-234-8720
  • Fax: 701-234-8779
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number673
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number46
License Number StateND
# 3
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number46
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: