Provider Demographics
NPI:1063405256
Name:ANDERSON, JEREMY WADE (OD)
Entity type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:WADE
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 1:1642 MCARTHUR ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:TN
Mailing Address - Zip Code:37355-2522
Mailing Address - Country:US
Mailing Address - Phone:931-728-1315
Mailing Address - Fax:931-728-1779
Practice Address - Street 1:1642 MCARTHUR ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:TN
Practice Address - Zip Code:37355-2522
Practice Address - Country:US
Practice Address - Phone:931-728-1315
Practice Address - Fax:931-728-1779
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2013-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2431152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN2431OtherLICENSE OD
TN3946295Medicaid
TN3946295Medicaid
V00785Medicare UPIN