Healthcare Provider Details

I. General information

NPI: 1598747909
Provider Name (Legal Business Name): WILLIAM STANTON ANDERSON III M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2005
Last Update Date: 03/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 EAST NIZHONI BLVD.
GALLUP NM
87301-1337
US

IV. Provider business mailing address

1501 SAN PEDRO DR SE # 182-C
ALBUQUERQUE NM
87108-5153
US

V. Phone/Fax

Practice location:
  • Phone: 505-722-1000
  • Fax: 505-726-8740
Mailing address:
  • Phone: 505-265-1711
  • Fax: 505-256-6414

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number11589
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: