Healthcare Provider Details

I. General information

NPI: 1598748790
Provider Name (Legal Business Name): RICK D ANDERSEN O.D, F.A.A.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/22/2005
Last Update Date: 12/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1421 WASHINGTON AVE
RACINE WI
53403-2254
US

IV. Provider business mailing address

1421 WASHINGTON AVE
RACINE WI
53403-2254
US

V. Phone/Fax

Practice location:
  • Phone: 262-637-7494
  • Fax:
Mailing address:
  • Phone: 262-637-7494
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1567
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number1567
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number1567
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: