Healthcare Provider Details

I. General information

NPI: 1386612927
Provider Name (Legal Business Name): BETTE L ANDERSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2006
Last Update Date: 03/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3015 VILLAGE OFFICE PL
CHAMPAIGN IL
61822-7674
US

IV. Provider business mailing address

3015 VILLAGE OFFICE PL
CHAMPAIGN IL
61822-7674
US

V. Phone/Fax

Practice location:
  • Phone: 217-355-7947
  • Fax: 217-355-8047
Mailing address:
  • Phone: 217-355-7947
  • Fax: 217-355-8047

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberBA0383757
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number036073436
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: