Provider Demographics
NPI:1962684852
Name:JEFFREY B ANDERSON OD PLLC
Entity type:Organization
Organization Name:JEFFREY B ANDERSON OD PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT
Authorized Official - Prefix:MS
Authorized Official - First Name:LYNETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:NORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-269-8182
Mailing Address - Street 1:PO BOX 188
Mailing Address - Street 2:
Mailing Address - City:MONTEVIDEO
Mailing Address - State:MN
Mailing Address - Zip Code:56265-0188
Mailing Address - Country:US
Mailing Address - Phone:320-269-8182
Mailing Address - Fax:320-269-5868
Practice Address - Street 1:602 LEGION DR
Practice Address - Street 2:
Practice Address - City:MONTEVIDEO
Practice Address - State:MN
Practice Address - Zip Code:56265-1709
Practice Address - Country:US
Practice Address - Phone:320-269-8182
Practice Address - Fax:320-269-5868
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-03
Last Update Date:2012-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1614152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN0340410001Medicare NSC
T65239Medicare UPIN
MN419000354Medicare PIN