Healthcare Provider Details

I. General information

NPI: 1962411009
Provider Name (Legal Business Name): LEE STEWART ANDERSON JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2006
Last Update Date: 11/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 ST. MICHAELS DRIVE
SANTA FE NM
87505
US

IV. Provider business mailing address

1640 OLD PECOS TRAIL SUITE H
SANTA FE NM
87505
US

V. Phone/Fax

Practice location:
  • Phone: 505-913-3934
  • Fax: 505-368-6431
Mailing address:
  • Phone: 505-992-0233
  • Fax: 505-992-0609

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number227729
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD2009-0234
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: