Provider Demographics
NPI:1477556488
Name:MAYGREN, ANNELLE GLEE (OD)
Entity Type:Individual
Prefix:
First Name:ANNELLE
Middle Name:GLEE
Last Name:MAYGREN
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 1:3100 CHANNEL DR STE 300
Mailing Address - Street 2:
Mailing Address - City:JUNEAU
Mailing Address - State:AK
Mailing Address - Zip Code:99801-7837
Mailing Address - Country:US
Mailing Address - Phone:907-463-4074
Mailing Address - Fax:907-463-1510
Practice Address - Street 1:333 COLD STORAGE ROAD
Practice Address - Street 2:
Practice Address - City:CRAIG
Practice Address - State:AK
Practice Address - Zip Code:99921
Practice Address - Country:US
Practice Address - Phone:907-755-4967
Practice Address - Fax:907-755-2414
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12333T152W00000X
OR2964T152W00000X
AK297152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1023212Medicaid
AKOPTT297OtherSTATE OF ALASKA
AKOD0035Medicaid
CAU95824Medicare UPIN
CASD0123330Medicaid
AK8EM363Medicare PIN