=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013135292
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PAUL B ANDERSON
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/23/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2656 ELLWOOD RD LAWRENCE VILLAGE PLAZA
-----------------------------------------------------
City | NEW CASTLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16101-6282
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-652-6430
-----------------------------------------------------
Fax | 724-652-4552
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2656 ELLWOOD RD LAWRENCE VILLAGE PLAZA
-----------------------------------------------------
City | NEW CASTLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16101-6282
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-652-6430
-----------------------------------------------------
Fax | 724-652-4552
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. PAUL BENJAMIN ANDERSON
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 724-652-6430
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OEG000349
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------