Provider Demographics
NPI:1164550596
Name:ANDERSON, JOHN ERIC (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ERIC
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:512 W BURLINGTON AVE
Mailing Address - Street 2:SUITE 106
Mailing Address - City:LA GRANGE
Mailing Address - State:IL
Mailing Address - Zip Code:60525-2221
Mailing Address - Country:US
Mailing Address - Phone:708-354-7001
Mailing Address - Fax:708-354-0716
Practice Address - Street 1:512 W BURLINGTON AVE
Practice Address - Street 2:SUITE 106
Practice Address - City:LA GRANGE
Practice Address - State:IL
Practice Address - Zip Code:60525-2221
Practice Address - Country:US
Practice Address - Phone:708-354-7001
Practice Address - Fax:708-354-0716
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046007314152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist