Provider Demographics
NPI:1679570899
Name:ANDERSEN, KATHLEEN (MD)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:ANDERSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 PETALUMA AVE
Mailing Address - Street 2:#A
Mailing Address - City:SEBASTOPOL
Mailing Address - State:CA
Mailing Address - Zip Code:95472-4224
Mailing Address - Country:US
Mailing Address - Phone:707-823-3210
Mailing Address - Fax:707-823-1710
Practice Address - Street 1:555 PETALUMA AVE
Practice Address - Street 2:#A
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472-4224
Practice Address - Country:US
Practice Address - Phone:707-823-3210
Practice Address - Fax:707-823-1710
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG58153207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G581530Medicare ID - Type Unspecified