Healthcare Provider Details

I. General information

NPI: 1023798790
Provider Name (Legal Business Name): DAVID ANDERSON OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2023
Last Update Date: 03/29/2026
Certification Date: 03/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3640 CORPORATE TRAIL DR
EARTH CITY MO
63045-1122
US

IV. Provider business mailing address

4321 MANCHESTER AVE APT 305
SAINT LOUIS MO
63110-2166
US

V. Phone/Fax

Practice location:
  • Phone: 314-388-0722
  • Fax:
Mailing address:
  • Phone: 573-230-3652
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2024016097
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC6304
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: