Healthcare Provider Details

I. General information

NPI: 1508060849
Provider Name (Legal Business Name): LORI ANN ANDERSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2007
Last Update Date: 05/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24988 SE STARK ST SUITE 200
GRESHAM OR
97030-8322
US

IV. Provider business mailing address

4348 NE 36TH AVE
PORTLAND OR
97211-8202
US

V. Phone/Fax

Practice location:
  • Phone: 503-667-8878
  • Fax: 503-667-0310
Mailing address:
  • Phone: 312-505-0655
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD29061
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: