Provider Demographics
NPI:1548227283
Name:ANDERSON, JAMES KEITH (OD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:KEITH
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:DR
Other - First Name:KEITH
Other - Middle Name:
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:4010 EAST NORTH STREET
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615
Mailing Address - Country:US
Mailing Address - Phone:864-292-0262
Mailing Address - Fax:864-292-1316
Practice Address - Street 1:4010 EAST NORTH STREET
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615
Practice Address - Country:US
Practice Address - Phone:864-292-0262
Practice Address - Fax:864-292-0262
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-27
Last Update Date:2012-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC648152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCOD0648Medicaid
SCOD0648Medicaid