Basic Information
| Provider Information | |||||||||
| NPI: | 1396967659 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | C.L. ANDERSON, JR., M.D., PLLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | VALLEY DAY AND NIGHT CLINIC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3302 BOCA CHICA BLVD STE 109 | ||||||||
| Address2: | |||||||||
| City: | BROWNSVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9569821001 | ||||||||
| FaxNumber: | 9569821938 | ||||||||
| Practice Location | |||||||||
| Address1: | 3302 BOCA CHICA BLVD STE 109 | ||||||||
| Address2: | |||||||||
| City: | BROWNSVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9569821001 | ||||||||
| FaxNumber: | 9569821938 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2007 | ||||||||
| LastUpdateDate: | 09/27/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ANDERSON | ||||||||
| AuthorizedOfficialFirstName: | C | ||||||||
| AuthorizedOfficialMiddleName: | LYNN | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9569821001 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | F6390 | TX | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 172803201 | 05 | TX | MEDICAID |