Provider Demographics
NPI:1548498991
Name:DENNIS ANDERSON OD
Entity type:Organization
Organization Name:DENNIS ANDERSON OD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:L
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:O,D
Authorized Official - Phone:812-288-7179
Mailing Address - Street 1:100 E 12TH ST
Mailing Address - Street 2:
Mailing Address - City:JEFFERSONVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47130-3834
Mailing Address - Country:US
Mailing Address - Phone:812-288-7179
Mailing Address - Fax:812-288-0203
Practice Address - Street 1:100 E 12TH ST
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130-3834
Practice Address - Country:US
Practice Address - Phone:812-288-7179
Practice Address - Fax:812-288-0203
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-24
Last Update Date:2009-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001580AB152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN0161480001Medicare NSC