Provider Demographics
NPI:1679564595
Name:ANDERSON, DONALD R (MD, FACC, FCCP, COL)
Entity type:Individual
Prefix:DR
First Name:DONALD
Middle Name:R
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MD, FACC, FCCP, COL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 W MONROE ST STE 266
Mailing Address - Street 2:
Mailing Address - City:WYTHEVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24382-2341
Mailing Address - Country:US
Mailing Address - Phone:202-294-7948
Mailing Address - Fax:
Practice Address - Street 1:175 W MONROE STE 266
Practice Address - Street 2:
Practice Address - City:WYTHEVILLE
Practice Address - State:VA
Practice Address - Zip Code:24382-2341
Practice Address - Country:US
Practice Address - Phone:202-294-7948
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-31
Last Update Date:2016-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA39277207RC0000X
VA0101246201207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00638404CMedicaid
VA1679564595Medicaid
VA1679564595Medicaid
VA00Y152C01Medicare PIN