Provider Demographics
NPI:1578600649
Name:ANDERSON, RICHARD L (OD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:L
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 1:484 MOBIL AVE STE 6
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93010-6359
Mailing Address - Country:US
Mailing Address - Phone:805-484-7903
Mailing Address - Fax:
Practice Address - Street 1:484 MOBIL AVE STE 6
Practice Address - Street 2:
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93010-6359
Practice Address - Country:US
Practice Address - Phone:805-484-7903
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6612152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0066120Medicaid
CASD0066120Medicaid