Provider Demographics
NPI:1376707984
Name:ANDERSON, ANNA R (OD)
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:R
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 JEFFERSON PKWY
Mailing Address - Street 2:APT #328
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-8847
Mailing Address - Country:US
Mailing Address - Phone:503-387-6190
Mailing Address - Fax:
Practice Address - Street 1:200 SW MARKET ST
Practice Address - Street 2:#L120
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97201-5715
Practice Address - Country:US
Practice Address - Phone:503-223-8147
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-12
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13504152W00000X
AZ1697152W00000X
OR3284AT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ554653Medicaid
AZZ140164Medicare PIN