Basic Information
| Provider Information | |||||||||
| NPI: | 1205831120 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 865 LINCOLN RD | ||||||||
| Address2: | STE L10 | ||||||||
| City: | BETTENDORF | ||||||||
| State: | IA | ||||||||
| PostalCode: | 527224159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5633559191 | ||||||||
| FaxNumber: | 5633553419 | ||||||||
| Practice Location | |||||||||
| Address1: | 210 W 53RD ST | ||||||||
| Address2: | |||||||||
| City: | DAVENPORT | ||||||||
| State: | IA | ||||||||
| PostalCode: | 528062251 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5633863436 | ||||||||
| FaxNumber: | 5633863211 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2005 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 01552 | IA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | IA0104 | 01 | JOHN DEERE HEALTH PLAN | OTHER | 4796890009 | 01 | DMERC | OTHER | 034792 | 01 | HEALTH ALLIANCE | OTHER | 1160432 | 05 | IA | MEDICAID | 20100 | 01 | IOWA HEALTH SOLUTIONS | OTHER | 40197 | 01 | IA | WELLMARK BC/BS | OTHER |