Basic Information
Provider Information
NPI: 1003002494
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: ANDERSON
FirstName: JOSEPH
MiddleName: MICHAEL
NamePrefix:  
NameSuffix:  
Credential: M.D.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 802 B ST
Address2:  
City: SAN RAFAEL
State: CA
PostalCode: 949013026
CountryCode: US
TelephoneNumber: 4157348726
FaxNumber: 4157624220
Practice Location
Address1: 802 B ST
Address2:  
City: SAN RAFAEL
State: CA
PostalCode: 949013026
CountryCode: US
TelephoneNumber: 4157348726
FaxNumber: 4157624220
Other Information
ProviderEnumerationDate: 09/19/2007
LastUpdateDate: 09/19/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207ZP0101XA98379CAY Allopathic & Osteopathic PhysiciansPathologyAnatomic Pathology

No ID Information.


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