Basic Information
| Provider Information | |||||||||
| NPI: | 1568479251 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | KRISTOFER | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 104 PORTER DR | ||||||||
| Address2: | PORTER PRACTICE MANAGEMENT | ||||||||
| City: | MIDDLEBURY | ||||||||
| State: | VT | ||||||||
| PostalCode: | 057538527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8023888808 | ||||||||
| FaxNumber: | 8023888322 | ||||||||
| Practice Location | |||||||||
| Address1: | 1330 EXCHANGE ST | ||||||||
| Address2: | SUITE 202 PORTER ENT | ||||||||
| City: | MIDDLEBURY | ||||||||
| State: | VT | ||||||||
| PostalCode: | 057534425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8023887037 | ||||||||
| FaxNumber: | 8023885657 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2006 | ||||||||
| LastUpdateDate: | 05/13/2008 | ||||||||
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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 | 207Y00000X | 0420011127 | VT | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 1012756 | 05 | VT | MEDICAID |