Provider Demographics
NPI:1083742159
Name:ANDERSON, MARIANNE (OD)
Entity Type:Individual
Prefix:DR
First Name:MARIANNE
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:951 N WALNUT CREEK DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-8025
Mailing Address - Country:US
Mailing Address - Phone:817-473-2850
Mailing Address - Fax:817-473-9771
Practice Address - Street 1:951 N WALNUT CREEK DR
Practice Address - Street 2:SUITE A
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-8025
Practice Address - Country:US
Practice Address - Phone:817-473-2850
Practice Address - Fax:817-473-9771
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2914152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXT11944Medicare UPIN
TX513307Medicare PIN