Healthcare Provider Details

I. General information

NPI: 1972981058
Provider Name (Legal Business Name): MARY ELIZABETH ANDERSON D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2015
Last Update Date: 10/18/2021
Certification Date: 10/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3551 ROGER BROOKE DR
FORT SAM HOUSTON TX
78234-4504
US

IV. Provider business mailing address

4270 GORGAS CIR BLDG 1070
FORT SAM HOUSTON TX
78234-2737
US

V. Phone/Fax

Practice location:
  • Phone: 210-539-9582
  • Fax:
Mailing address:
  • Phone: 210-916-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number0102204609
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: