Provider Demographics
NPI:1063068328
Name:ANDERSON, AUSTIN (OD)
Entity type:Individual
Prefix:
First Name:AUSTIN
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4505 E GREENSTREET CIR
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-8425
Mailing Address - Country:US
Mailing Address - Phone:079-376-2020
Mailing Address - Fax:907-357-3937
Practice Address - Street 1:4505 E GREENSTREET CIR
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-8425
Practice Address - Country:US
Practice Address - Phone:079-376-2020
Practice Address - Fax:907-357-3937
Is Sole Proprietor?:No
Enumeration Date:2019-08-13
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK147991152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist