Provider Demographics
NPI:1598748790
Name:ANDERSEN, RICK D (OD, FAAO)
Entity Type:Individual
Prefix:DR
First Name:RICK
Middle Name:D
Last Name:ANDERSEN
Suffix:
Gender:M
Credentials:OD, FAAO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1421 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53403-2254
Mailing Address - Country:US
Mailing Address - Phone:262-637-7494
Mailing Address - Fax:
Practice Address - Street 1:1421 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53403-2254
Practice Address - Country:US
Practice Address - Phone:262-637-7494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-22
Last Update Date:2008-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1567152W00000X, 152WP0200X, 152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38594700Medicaid
WI000587293Medicare ID - Type Unspecified
WIU25333Medicare UPIN
WI000587293Medicare PIN