Provider Demographics
NPI:1154982551
Name:ANDERSON, MITCHEL RYAN (OD)
Entity type:Individual
Prefix:
First Name:MITCHEL
Middle Name:RYAN
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 1:2949 CAMINO PIEDRA LUMBRE
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-5379
Mailing Address - Country:US
Mailing Address - Phone:435-851-9281
Mailing Address - Fax:
Practice Address - Street 1:1700 CERRILLOS RD
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-3026
Practice Address - Country:US
Practice Address - Phone:505-988-9821
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-26
Last Update Date:2019-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11323320-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist