Healthcare Provider Details

I. General information

NPI: 1033101043
Provider Name (Legal Business Name): ANDREA JEAN ANDERSON O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2005
Last Update Date: 06/30/2021
Certification Date: 06/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 E TIPTON ST
SEYMOUR IN
47274-3560
US

IV. Provider business mailing address

6073 CHINKAPIN DR
COLUMBUS IN
47201-8448
US

V. Phone/Fax

Practice location:
  • Phone: 812-523-6787
  • Fax: 812-523-6969
Mailing address:
  • Phone: 812-371-7544
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number18002664
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: