Provider Demographics
NPI:1083726855
Name:ANDERSON, LANCE GENE (OD)
Entity Type:Individual
Prefix:DR
First Name:LANCE
Middle Name:GENE
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 1:2037 NW 185TH AVE
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97124-7073
Mailing Address - Country:US
Mailing Address - Phone:503-690-9200
Mailing Address - Fax:503-690-6189
Practice Address - Street 1:2037 NW 185TH AVE
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97124-7073
Practice Address - Country:US
Practice Address - Phone:503-690-9200
Practice Address - Fax:503-690-6189
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2298 ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR93-1098521OtherEIN
ORU35292Medicare UPIN
OR0000PHLCBMedicare ID - Type Unspecified