Provider Demographics
NPI:1275719387
Name:ANDERSEN, THOMAS L (OD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:L
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 1:1645 N READING RD
Mailing Address - Street 2:
Mailing Address - City:STEVENS
Mailing Address - State:PA
Mailing Address - Zip Code:17578-9306
Mailing Address - Country:US
Mailing Address - Phone:717-336-5100
Mailing Address - Fax:717-336-7125
Practice Address - Street 1:1645 N READING RD
Practice Address - Street 2:
Practice Address - City:STEVENS
Practice Address - State:PA
Practice Address - Zip Code:17578-9306
Practice Address - Country:US
Practice Address - Phone:717-336-5100
Practice Address - Fax:717-336-7125
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-18
Last Update Date:2008-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOE004581P152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0008935780003Medicaid
PA060807Medicare PIN
PAT27773Medicare UPIN
PA0559120001Medicare NSC