Basic Information
| Provider Information | |||||||||
| NPI: | 1326105628 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | DUANE | ||||||||
| MiddleName: | RAY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 850 W IRONWOOD DR STE 202 | ||||||||
| Address2: | |||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838144903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086642175 | ||||||||
| FaxNumber: | 2086641226 | ||||||||
| Practice Location | |||||||||
| Address1: | 850 W IRONWOOD DR STE 202 | ||||||||
| Address2: | |||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838144903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086642175 | ||||||||
| FaxNumber: | 2086641226 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2007 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | M6376 | ID | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | M6376 | 01 | ID | LICENSE | OTHER |