Provider Demographics
NPI:1154469690
Name:ANDERSON, KENNETH WILLIAM (OD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:WILLIAM
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:DR
Other - First Name:KENNETH
Other - Middle Name:WILLIAM
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:1939 OXFORD CT
Mailing Address - Street 2:
Mailing Address - City:SALINAS
Mailing Address - State:CA
Mailing Address - Zip Code:93906-2184
Mailing Address - Country:US
Mailing Address - Phone:831-443-3912
Mailing Address - Fax:831-663-3277
Practice Address - Street 1:8048 SAN MIGUEL CANYON RD
Practice Address - Street 2:
Practice Address - City:SALINAS
Practice Address - State:CA
Practice Address - Zip Code:93907-1208
Practice Address - Country:US
Practice Address - Phone:831-663-3276
Practice Address - Fax:831-663-3277
Is Sole Proprietor?:No
Enumeration Date:2007-02-04
Last Update Date:2009-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5625T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU19529Medicare UPIN
CABP777ZMedicare PIN