Healthcare Provider Details

I. General information

NPI: 1255520326
Provider Name (Legal Business Name): AIYANNA B ANDERSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2007
Last Update Date: 10/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 PENNSYLVANIA AVE SUITE 600
FORT WORTH TX
76104-2158
US

IV. Provider business mailing address

1325 PENNSYLVANIA AVE SUITE 600
FORT WORTH TX
76104-2158
US

V. Phone/Fax

Practice location:
  • Phone: 817-878-5298
  • Fax: 817-878-5289
Mailing address:
  • Phone: 817-878-5298
  • Fax: 817-878-5289

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number25MA08247500
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License Number25MA08247500
License Number StateNJ
# 3
Primary TaxonomyY
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License NumberN5598
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License Number58398
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: