Provider Demographics
NPI:1447239736
Name:ANDERSON, KEVIN JOHN (OD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:JOHN
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 1:4103 BOARDWALK STE 100
Mailing Address - Street 2:
Mailing Address - City:FT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-5931
Mailing Address - Country:US
Mailing Address - Phone:970-223-0592
Mailing Address - Fax:970-377-1082
Practice Address - Street 1:4103 BOARDWALK STE 100
Practice Address - Street 2:
Practice Address - City:FT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-5931
Practice Address - Country:US
Practice Address - Phone:970-223-0592
Practice Address - Fax:970-377-1082
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-13
Last Update Date:2011-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCO1342152WC0802X, 152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04011250Medicaid
T60876Medicare UPIN
CO04011250Medicaid