Provider Demographics
NPI:1003945403
Name:ANDERSON, STEVEN R (OD)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:R
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 1:114 S COURT ST
Mailing Address - Street 2:
Mailing Address - City:SULLIVAN
Mailing Address - State:IN
Mailing Address - Zip Code:47882-1801
Mailing Address - Country:US
Mailing Address - Phone:812-268-4668
Mailing Address - Fax:812-268-4668
Practice Address - Street 1:114 S COURT ST
Practice Address - Street 2:
Practice Address - City:SULLIVAN
Practice Address - State:IN
Practice Address - Zip Code:47882-1801
Practice Address - Country:US
Practice Address - Phone:812-268-4668
Practice Address - Fax:812-268-4668
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-04
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001952A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
INU21112Medicare UPIN
IN0480670001Medicare NSC
IN165140Medicare PIN