Healthcare Provider Details

I. General information

NPI: 1376535310
Provider Name (Legal Business Name): LEE E ANDERSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2005
Last Update Date: 08/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 W CANNON ST
FORT WORTH TX
76104-3029
US

IV. Provider business mailing address

1000 W CANNON ST
FORT WORTH TX
76104-3029
US

V. Phone/Fax

Practice location:
  • Phone: 817-877-5858
  • Fax: 817-335-4418
Mailing address:
  • Phone: 817-877-5858
  • Fax: 817-335-4418

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberF3023
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: