Provider Demographics
NPI:1255329827
Name:ANDERSON, DONALD LEE (OPTICIAN LDO)
Entity Type:Individual
Prefix:MR
First Name:DONALD
Middle Name:LEE
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:OPTICIAN LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1890 SAM RITTENBERG BLVD STE 107
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407-4801
Mailing Address - Country:US
Mailing Address - Phone:843-763-2020
Mailing Address - Fax:843-763-2021
Practice Address - Street 1:1890 SAM RITTENBERG BLVD STE 107
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-4801
Practice Address - Country:US
Practice Address - Phone:843-763-2020
Practice Address - Fax:843-763-2021
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-07
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC154156FC0800X
SC551156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
No156FC0800XEye and Vision Services ProvidersTechnician/TechnologistContact Lens
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSC0551OtherEYEMED PROVIDER #
SC54825OtherVERSANT
SCOV0000405618OtherCLARITY VISION PROVIDER #