Provider Demographics
NPI:1336145481
Name:BISSELL, AMANDA JESSIE (OD)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:JESSIE
Last Name:BISSELL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:40 E NORTH ST
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:MO
Mailing Address - Zip Code:63025-1205
Mailing Address - Country:US
Mailing Address - Phone:636-200-4393
Mailing Address - Fax:636-938-2650
Practice Address - Street 1:3071 PHOENIX CENTER DR
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:MO
Practice Address - Zip Code:63090-5690
Practice Address - Country:US
Practice Address - Phone:636-777-2345
Practice Address - Fax:636-777-2115
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2014-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004025214152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO319102232Medicaid
MOP00374002OtherRAILROAD MEDICARE
MO257536438Medicare PIN
MO0030014545Medicare PIN
MOP00374002OtherRAILROAD MEDICARE
MOMA5227003Medicare UPIN
V03676Medicare UPIN