Provider Demographics
NPI:1609804921
Name:ANDERSEN, EDWARD PAUL
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:PAUL
Last Name:ANDERSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 E GRANT AVE
Mailing Address - Street 2:
Mailing Address - City:WINTERS
Mailing Address - State:CA
Mailing Address - Zip Code:95694-1761
Mailing Address - Country:US
Mailing Address - Phone:530-795-2551
Mailing Address - Fax:530-795-0934
Practice Address - Street 1:101 E GRANT AVE
Practice Address - Street 2:
Practice Address - City:WINTERS
Practice Address - State:CA
Practice Address - Zip Code:95694-1761
Practice Address - Country:US
Practice Address - Phone:530-795-2551
Practice Address - Fax:530-795-0934
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-28
Last Update Date:2011-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9669T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU22648Medicare UPIN
CA1167610002Medicare NSC