MEDICARE: DR. JEREMY WADE ANDERSON OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	2431	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2431	OTHER	TN	LICENSE OD
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1063405256
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEREMY WADE ANDERSON OD

Provider Business Mailing Address
First Line	:	1642 MCARTHUR ST
Second Line	:
City	:	MANCHESTER
State	:	TN
Zip	:	37355-2522
Country	:	US
Telephone Number	:	931-728-1315
Fax Number	:	931-728-1779

Provider Business Practice Location Address
First Line	:	1642 MCARTHUR ST
Second Line	:
City	:	MANCHESTER
State	:	TN
Zip	:	37355-2522
Country	:	US
Telephone Number	:	931-728-1315
Fax Number	:	931-728-1779

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/24/2005
Last Update Date	:	01/14/2013

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