Basic Information
| Provider Information | |||||||||
| NPI: | 1558362657 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | BRAD | ||||||||
| MiddleName: | DOUGLAS | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5920 MCINTYRE ST | ||||||||
| Address2: | |||||||||
| City: | GOLDEN | ||||||||
| State: | CO | ||||||||
| PostalCode: | 804037445 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7204344876 | ||||||||
| FaxNumber: | 3032254246 | ||||||||
| Practice Location | |||||||||
| Address1: | 90 HEALTH PARK DR | ||||||||
| Address2: | SUITE 260 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800279757 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3036739090 | ||||||||
| FaxNumber: | 3036739195 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2005 | ||||||||
| LastUpdateDate: | 04/21/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 37641 | CO | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 50305255 | 05 | CO | MEDICAID |