Provider Demographics
NPI:1366450686
Name:ANDERSEN, JEFFREY R (OD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:R
Last Name:ANDERSEN
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 1:1310 PRENTICE DR
Mailing Address - Street 2:SUITE F
Mailing Address - City:HEALDSBURG
Mailing Address - State:CA
Mailing Address - Zip Code:95448-3384
Mailing Address - Country:US
Mailing Address - Phone:707-433-9475
Mailing Address - Fax:707-499-2013
Practice Address - Street 1:1310 PRENTICE DR
Practice Address - Street 2:SUITE F
Practice Address - City:HEALDSBURG
Practice Address - State:CA
Practice Address - Zip Code:95448-3384
Practice Address - Country:US
Practice Address - Phone:707-433-9475
Practice Address - Fax:707-499-2013
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAOPT7408T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPT7408TOtherOPTOMETRY LICENSE
CAZZZ13801ZOtherPTAN
CAZZZ42820ZOtherPTAN
CAZZZ13802ZOtherGROUP PTAN
CAZZZ42820ZOtherPTAN