Provider Demographics
NPI:1154489177
Name:ANDERSON, VALERIE RENEE (OD)
Entity type:Individual
Prefix:DR
First Name:VALERIE
Middle Name:RENEE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:930 CHIPPEWA DR
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-4502
Mailing Address - Country:US
Mailing Address - Phone:219-310-8912
Mailing Address - Fax:
Practice Address - Street 1:9270 WICKER AVE
Practice Address - Street 2:SUITE A
Practice Address - City:SAINT JOHN
Practice Address - State:IN
Practice Address - Zip Code:46373-8508
Practice Address - Country:US
Practice Address - Phone:219-365-1227
Practice Address - Fax:219-365-1552
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2013-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003351152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200521640Medicaid
IN708660HMedicare ID - Type Unspecified
INV05532Medicare UPIN