Healthcare Provider Details

I. General information

NPI: 1235130709
Provider Name (Legal Business Name): WILLIAM ROBERT ANDERSON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 12/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 N MAIN
GORE OK
74435
US

IV. Provider business mailing address

PO BOX 479
GORE OK
74435
US

V. Phone/Fax

Practice location:
  • Phone: 918-489-5757
  • Fax: 918-489-5411
Mailing address:
  • Phone: 918-489-5757
  • Fax: 918-489-5411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2597
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: