Provider Demographics
NPI:1093791386
Name:ANDERSEN, JOSEPH LEIF (OD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:LEIF
Last Name:ANDERSEN
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 1:4319 LAWRENCEVILLE HWY NW
Mailing Address - Street 2:
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-3416
Mailing Address - Country:US
Mailing Address - Phone:770-921-4707
Mailing Address - Fax:770-925-8973
Practice Address - Street 1:4319 LAWRENCEVILLE HWY NW
Practice Address - Street 2:
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047-3416
Practice Address - Country:US
Practice Address - Phone:770-921-4707
Practice Address - Fax:770-925-8973
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2015-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1432152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
410029607OtherMEDICARE RAILROAD
41ZCCRKOtherPTAN
0154870002Medicare NSC
41ZCCRKOtherPTAN