Provider Demographics
NPI:1083142251
Name:ANDERSON, ROBERT OWEN (OD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:OWEN
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 1:15160 FOLIAGE AVE STE 180
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55124-5916
Mailing Address - Country:US
Mailing Address - Phone:952-953-4151
Mailing Address - Fax:
Practice Address - Street 1:15160 FOLIAGE AVE STE 180
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55124-5916
Practice Address - Country:US
Practice Address - Phone:952-953-4151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-31
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3506152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist