=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538341201
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KEVIN B. ANDERSON, DO, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/04/2007
-----------------------------------------------------
Last Update Date | 12/04/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2700 CITIZENS PLZ SUITE 204
-----------------------------------------------------
City | VICTORIA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77901-5754
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 361-574-1832
-----------------------------------------------------
Fax | 361-574-1833
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2700 CITIZENS PLZ SUITE 204
-----------------------------------------------------
City | VICTORIA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77901-5754
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 361-574-1832
-----------------------------------------------------
Fax | 361-574-1833
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PRESIDENT
-----------------------------------------------------
Name | KEVIN B ANDERSON
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 361-574-1832
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | M7826
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------