Healthcare Provider Details

I. General information

NPI: 1710983044
Provider Name (Legal Business Name): PATRICIA ANDERSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2005
Last Update Date: 06/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1065 SOUTHERN BLVD
BRONX NY
10459-2417
US

IV. Provider business mailing address

1065 SOUTHERN BLVD
BRONX NY
10459-2417
US

V. Phone/Fax

Practice location:
  • Phone: 718-589-2440
  • Fax:
Mailing address:
  • Phone: 718-589-2440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number204242
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: