Provider Demographics
NPI:1073523304
Name:ANDERSON, THOMAS LEE (OD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:LEE
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 1:118 TANGLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:DODGE CITY
Mailing Address - State:KS
Mailing Address - Zip Code:67801-2143
Mailing Address - Country:US
Mailing Address - Phone:620-408-9353
Mailing Address - Fax:
Practice Address - Street 1:2520 N 14TH AVE
Practice Address - Street 2:
Practice Address - City:DODGE CITY
Practice Address - State:KS
Practice Address - Zip Code:67801-2315
Practice Address - Country:US
Practice Address - Phone:620-227-3071
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1675152W00000X
MO2006023500152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSV02185Medicare UPIN
KS651029Medicare ID - Type Unspecified