Provider Demographics
NPI:1598881534
Name:ANDERSON, MITCHELL RAY (OD)
Entity Type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:RAY
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:571-223-6780
Practice Address - Street 1:8215 S MINGO RD STE 100
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-4671
Practice Address - Country:US
Practice Address - Phone:918-252-7432
Practice Address - Fax:918-250-9003
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1069152WC0802X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKANDE23832OtherSPECTERA
OK274812801OtherFEDERAL ID
OK9184554545OtherVSP
OK9745OtherAVESIS
OK3518OtherSUPERIOR VISION
OK112326OtherEYEMED
OK1598881534OtherBCBS OF OKLAHOMA
OK3518OtherSUPERIOR VISION
OK0310730001Medicare ID - Type UnspecifiedDMERC#