Provider Demographics
NPI:1194718122
Name:ANDERSON, JOHN T (OD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:T
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 1:251 N SAWYER ST
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54902-4251
Mailing Address - Country:US
Mailing Address - Phone:920-235-5530
Mailing Address - Fax:920-235-6406
Practice Address - Street 1:251 N SAWYER ST
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54902-4251
Practice Address - Country:US
Practice Address - Phone:920-235-5530
Practice Address - Fax:920-235-5530
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIWI1919152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI631000OtherVIP
WI18763OtherSPECTERA
WI19336OtherNVA
WI38521800Medicaid
WI19336OtherNVA
WI631000OtherVIP