Provider Demographics
NPI:1598864514
Name:ANDERSON, JEFF BRUCE (OD)
Entity Type:Individual
Prefix:DR
First Name:JEFF
Middle Name:BRUCE
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 1:116 KRESTWOOD DRIVE
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337
Mailing Address - Country:US
Mailing Address - Phone:952-223-1270
Mailing Address - Fax:
Practice Address - Street 1:1360 TOWN CENTRE DR
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55123
Practice Address - Country:US
Practice Address - Phone:651-686-7435
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2956152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN2202818OtherMEDICA
MN2203374OtherMEDICA
MN2202941OtherMEDICA
MN979851041639OtherPERFERRED ONE
MN328M9ANOtherBLUE CROSS BLUE SHIELD
MN979851041639OtherPERFERRED ONE