Provider Demographics
NPI:1427021062
Name:ANDERSON, MARK D (OD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:D
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 1:25 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:KINGWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:77339-3710
Mailing Address - Country:US
Mailing Address - Phone:281-361-2020
Mailing Address - Fax:281-361-0702
Practice Address - Street 1:25 N MAIN ST
Practice Address - Street 2:
Practice Address - City:KINGWOOD
Practice Address - State:TX
Practice Address - Zip Code:77339-3710
Practice Address - Country:US
Practice Address - Phone:281-361-2020
Practice Address - Fax:281-361-0702
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2009-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3906TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T91169Medicare UPIN
TX1031820001Medicare NSC
TX83584EMedicare PIN