Basic Information
| Provider Information | |||||||||
| NPI: | 1457452922 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | CARROL | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3302 BOCA CHICA BLVD STE 109 | ||||||||
| Address2: | |||||||||
| City: | BROWNSVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 785214271 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9569821001 | ||||||||
| FaxNumber: | 9569821938 | ||||||||
| Practice Location | |||||||||
| Address1: | 3302 BOCA CHICA BLVD STE 109 | ||||||||
| Address2: | |||||||||
| City: | BROWNSVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 785214271 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9569821001 | ||||||||
| FaxNumber: | 9569821938 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2006 | ||||||||
| LastUpdateDate: | 01/03/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | F6390 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine | 208D00000X | F6390 | TX | N | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 172803202 | 01 | TX | MEDICAID TEXAS HEALTH STEPS NUMBER | OTHER | 140145728 | 05 | TX | MEDICAID | 172803201 | 01 | TX | MEDICAID GROUP NUMBER | OTHER | 00345Y | 01 | TX | MEDICARE GROUP NUMBER | OTHER |