Individual
JACK ANDERSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
2500 E CAPITOL DR, APPLETON, WI 54911-8735
(920) 731-5811
(920) 738-6293
Mailing address
PO BOX 8003, APPLETON, WI 54912-8003
(920) 996-3298
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
26238-020
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
110048483
RR MEDICARE
—
05
—
30608500
—
WI
01
—
450030618
MEDICARE PTAN
WI
01
—
711290042
MEDICARE PTAN
WI
Enumeration date
07/06/2006
Last updated
11/16/2011
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