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General NPI Number Information
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NPI Number | 1366490773
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Entity Type | Individual
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Provider Name | JOHN ROGER ANDERSON D.O.
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Gender | Male
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Dates
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Enumeration Date | 05/05/2006
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Last Update Date | 08/04/2023
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Provider Practice Location Address
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Address Line | 8611 W EAGLE RIDGE RD
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City | COEUR D ALENE
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State | ID
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Zip | 83814-9565
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Country | US
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Telephone | 208-664-4455
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Fax | 208-664-4159
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Provider Business Mailing Address
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Address Line | 8611 W EAGLE RIDGE RD
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City | COEUR D ALENE
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State | ID
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Zip | 83814-9565
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Country | US
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Telephone | 208-664-4455
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Fax | 208-664-4159
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | 0102204169
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License Number State | VA
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Taxonomy #2
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | O-0349
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License Number State | ID
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