Provider Demographics
NPI:1437277225
Name:THOMAS L ANDERSEN OD PC
Entity Type:Organization
Organization Name:THOMAS L ANDERSEN OD PC
Other - Org Name:COCALICO VISION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:L
Authorized Official - Last Name:ANDERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:717-336-5100
Mailing Address - Street 1:1645 N READING RD
Mailing Address - Street 2:
Mailing Address - City:STEVENS
Mailing Address - State:PA
Mailing Address - Zip Code:17578-9306
Mailing Address - Country:US
Mailing Address - Phone:717-336-5100
Mailing Address - Fax:717-336-7125
Practice Address - Street 1:1645 N READING RD
Practice Address - Street 2:
Practice Address - City:STEVENS
Practice Address - State:PA
Practice Address - Zip Code:17578-9306
Practice Address - Country:US
Practice Address - Phone:717-336-5100
Practice Address - Fax:717-336-7125
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOE004581P152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0008935780003Medicaid
PA0559120001Medicare NSC
T27773Medicare UPIN
PA060807Medicare PIN