Provider Demographics
NPI:1114361888
Name:ANDERSON, KRISHAAN G (OD)
Entity Type:Individual
Prefix:DR
First Name:KRISHAAN
Middle Name:G
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 1:534 N HARRISVILLE RD
Mailing Address - Street 2:
Mailing Address - City:HARRISVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84404-3532
Mailing Address - Country:US
Mailing Address - Phone:801-737-0657
Mailing Address - Fax:801-737-0670
Practice Address - Street 1:534 N HARRISVILLE RD
Practice Address - Street 2:
Practice Address - City:HARRISVILLE
Practice Address - State:UT
Practice Address - Zip Code:84404-3532
Practice Address - Country:US
Practice Address - Phone:801-737-0657
Practice Address - Fax:801-737-0670
Is Sole Proprietor?:No
Enumeration Date:2013-04-24
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013006595152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOMA5227064Medicare UPIN