Provider Demographics
NPI:1437882578
Name:ANDERSON, AMBER (OD)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:
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 1:3028 WILLIE DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHPORT
Mailing Address - State:FL
Mailing Address - Zip Code:32409-1781
Mailing Address - Country:US
Mailing Address - Phone:815-977-0620
Mailing Address - Fax:
Practice Address - Street 1:2500 MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-4412
Practice Address - Country:US
Practice Address - Phone:850-878-0191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-06
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046.011632152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist