Basic Information
| Provider Information | |||||||||
| NPI: | 1669410213 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GANDERSON | ||||||||
| FirstName: | ALAN | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1112 WINDSOR RD | ||||||||
| Address2: | |||||||||
| City: | VIRGINIA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234513752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574251114 | ||||||||
| FaxNumber: | 7579635585 | ||||||||
| Practice Location | |||||||||
| Address1: | 1101 FIRST COLONIAL RD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | VIRGINIA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234542409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574812127 | ||||||||
| FaxNumber: | 7574817138 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2006 | ||||||||
| LastUpdateDate: | 10/31/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 0101019855 | VA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 010119341 | 05 | VA | MEDICAID |