Provider Demographics
NPI:1497759344
Name:ANDERSON, DAVID M (OD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:M
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 1:340 ALEXANDERSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45342-2554
Mailing Address - Country:US
Mailing Address - Phone:937-866-3471
Mailing Address - Fax:
Practice Address - Street 1:340 ALEXANDERSVILLE RD
Practice Address - Street 2:
Practice Address - City:MIAMISBURG
Practice Address - State:OH
Practice Address - Zip Code:45342-2554
Practice Address - Country:US
Practice Address - Phone:937-866-3471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2013-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5457152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHV04253Medicare UPIN
OH4153711Medicare PIN