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General NPI Number Information
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NPI Number | 1821640517
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Entity Type | Individual
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Provider Name | DUSTIN WILLIAM ANDERSON
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Gender | Male
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Dates
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Enumeration Date | 07/12/2019
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Last Update Date | 10/07/2024
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Provider Practice Location Address
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Address Line | 1011 BOWLES AVE STE 200
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City | FENTON
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State | MO
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Zip | 63026-2384
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Country | US
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Telephone | 636-717-1700
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Fax | 636-203-4727
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Provider Business Mailing Address
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Address Line | PO BOX 207158
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City | DALLAS
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State | TX
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Zip | 75320-7158
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Country | US
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Telephone | 636-200-4393
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 2019021861
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License Number State | MO
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