=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154489177
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VALERIE RENEE ANDERSON O.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/04/2006
-----------------------------------------------------
Last Update Date | 12/31/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9270 WICKER AVE SUITE A
-----------------------------------------------------
City | SAINT JOHN
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46373-8508
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-365-1227
-----------------------------------------------------
Fax | 219-365-1552
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 930 CHIPPEWA DR
-----------------------------------------------------
City | CROWN POINT
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46307-4502
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-310-8912
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 18003351
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------