MEDICARE: DR. KERRY SCOT ANDERSON O.D.

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	OPT 9775 TPA	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1851404628
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KERRY SCOT ANDERSON O.D.

Provider Business Mailing Address
First Line	:	21078 JEWEL CT
Second Line	:
City	:	DIAMOND BAR
State	:	CA
Zip	:	91765-4038
Country	:	US
Telephone Number	:	909-628-8860
Fax Number	:	909-628-6120

Provider Business Practice Location Address
First Line	:	14335 PIPELINE AVE
Second Line	:
City	:	CHINO
State	:	CA
Zip	:	91710-5642
Country	:	US
Telephone Number	:	909-628-8860
Fax Number	:	909-628-6120

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

Provider Enumeration Date	:	08/16/2006
Last Update Date	:	12/28/2012

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