Healthcare Provider Details

I. General information

NPI: 1427044916
Provider Name (Legal Business Name): JEFFREY L ANDERSON OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2005
Last Update Date: 03/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 14TH ST NW
AUSTIN MN
55912-4645
US

IV. Provider business mailing address

200 14TH ST NW
AUSTIN MN
55912-4645
US

V. Phone/Fax

Practice location:
  • Phone: 507-437-3227
  • Fax: 507-437-8070
Mailing address:
  • Phone: 507-437-3227
  • Fax: 507-437-8070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2665
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: