Healthcare Provider Details

I. General information

NPI: 1447239736
Provider Name (Legal Business Name): KEVIN JOHN ANDERSON OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/13/2006
Last Update Date: 01/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4103 BOARDWALK STE 100
FT COLLINS CO
80525-5931
US

IV. Provider business mailing address

4103 BOARDWALK STE 100
FT COLLINS CO
80525-5931
US

V. Phone/Fax

Practice location:
  • Phone: 970-223-0592
  • Fax: 970-377-1082
Mailing address:
  • Phone: 970-223-0592
  • Fax: 970-377-1082

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberCO1342
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code152WX0102X
TaxonomyOccupational Vision Optometrist
License NumberCO1342
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier04011250
Identifier TypeMEDICAID
Identifier StateCO
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: