Provider Demographics
NPI:1376534198
Name:ANDERSON, KENNETH MICHAEL (OD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:MICHAEL
Last Name:ANDERSON
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 1:977 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MONTEVALLO
Mailing Address - State:AL
Mailing Address - Zip Code:35115-3847
Mailing Address - Country:US
Mailing Address - Phone:205-665-1488
Mailing Address - Fax:205-665-5128
Practice Address - Street 1:977 MAIN ST
Practice Address - Street 2:
Practice Address - City:MONTEVALLO
Practice Address - State:AL
Practice Address - Zip Code:35115-3847
Practice Address - Country:US
Practice Address - Phone:205-665-1488
Practice Address - Fax:205-665-5128
Is Sole Proprietor?:No
Enumeration Date:2005-11-01
Last Update Date:2009-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS495TA007152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000059718Medicare ID - Type Unspecified