Healthcare Provider Details

I. General information

NPI: 1619964855
Provider Name (Legal Business Name): JEFFREY B ANDERSON O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2005
Last Update Date: 12/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

602 LEGION DR
MONTEVIDEO MN
56265-1709
US

IV. Provider business mailing address

PO BOX 188
MONTEVIDEO MN
56265-0188
US

V. Phone/Fax

Practice location:
  • Phone: 320-269-8182
  • Fax: 320-269-5868
Mailing address:
  • Phone: 320-269-8182
  • Fax: 320-269-5868

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1614
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: