=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699701466
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DOUGLAS JEFFERSON ANDERSON M. D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/24/2006
-----------------------------------------------------
Last Update Date | 07/09/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 500 N WASHINGTON AVE SUITE 208
-----------------------------------------------------
City | TITUSVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32796-2759
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-269-3808
-----------------------------------------------------
Fax | 321-267-9156
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2621 TOUPS TRL
-----------------------------------------------------
City | TITUSVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32780-6754
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-383-8484
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | ME0052042
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------