Healthcare Provider Details

I. General information

NPI: 1063338671
Provider Name (Legal Business Name): ANDERSON LAO OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2026
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 BLUE RAVINE RD
FOLSOM CA
95630-3822
US

IV. Provider business mailing address

404 BLUE RAVINE RD
FOLSOM CA
95630-3822
US

V. Phone/Fax

Practice location:
  • Phone: 916-983-9985
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number36285
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: