Provider Demographics
NPI:1043236177
Name:ANDERSON, MARK JEROME (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:JEROME
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1202 N CENTER ST
Mailing Address - Street 2:
Mailing Address - City:HICKORY
Mailing Address - State:NC
Mailing Address - Zip Code:28601-3760
Mailing Address - Country:US
Mailing Address - Phone:828-322-4344
Mailing Address - Fax:828-323-8450
Practice Address - Street 1:1202 N CENTER ST
Practice Address - Street 2:
Practice Address - City:HICKORY
Practice Address - State:NC
Practice Address - Zip Code:28601-3760
Practice Address - Country:US
Practice Address - Phone:828-322-4344
Practice Address - Fax:828-323-8450
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC35092208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8911247Medicaid
NCE09219Medicare UPIN
NC8911247Medicaid