MEDICARE: DR. LARRY W. ANDERSON D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	020648	GA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00419457	OTHER	GA	RAILROAD MEDICARE PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	08BCBCN	OTHER	GA	LEGACY

General Provider Information

NPI Number	:	1932157856
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LARRY W. ANDERSON D.O.

Provider Business Mailing Address
First Line	:	81 NORTHSIDE DAWSON DR
Second Line	:	STE 205
City	:	DAWSONVILLE
State	:	GA
Zip	:	30534-7166
Country	:	US
Telephone Number	:	706-265-1335
Fax Number	:	706-265-2296

Provider Business Practice Location Address
First Line	:	81 NORTHSIDE DAWSON DR
Second Line	:	STE 205
City	:	DAWSONVILLE
State	:	GA
Zip	:	30534-7166
Country	:	US
Telephone Number	:	706-265-1335
Fax Number	:	706-265-2296

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/04/2006
Last Update Date	:	08/07/2020

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