Provider Demographics
NPI:1124079934
Name:ANDERSON, JONATHAN P (OD)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:P
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 1:225 W ASHLAND AVE
Mailing Address - Street 2:STE 1
Mailing Address - City:INDIANOLA
Mailing Address - State:IA
Mailing Address - Zip Code:50125-2462
Mailing Address - Country:US
Mailing Address - Phone:515-961-5305
Mailing Address - Fax:515-961-9225
Practice Address - Street 1:225 W ASHLAND
Practice Address - Street 2:STE 1
Practice Address - City:INDIANOLA
Practice Address - State:IA
Practice Address - Zip Code:50125
Practice Address - Country:US
Practice Address - Phone:515-961-5305
Practice Address - Fax:515-961-9225
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02145152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA2278069Medicaid
IA0278069Medicaid
IA1278069Medicaid
IAI8596Medicare PIN
IA1278069Medicaid
IA0278069Medicaid
IA2278069Medicaid