Provider Demographics
NPI:1467527523
Name:ANDERSON, CAROL L (MD)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:L
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5161 PLEASANT AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45014-2639
Mailing Address - Country:US
Mailing Address - Phone:513-896-1578
Mailing Address - Fax:513-896-1687
Practice Address - Street 1:5161 PLEASANT AVE
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:OH
Practice Address - Zip Code:45014-2639
Practice Address - Country:US
Practice Address - Phone:513-896-1578
Practice Address - Fax:513-896-1687
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-22
Last Update Date:2011-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH325-051202207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH31192739026Medicaid
OH0675443Medicaid
000000014329OtherANTHEM
OH31192739026Medicaid
000000014329OtherANTHEM