Provider Demographics
NPI:1619918935
Name:ANDERSON, JILL SUSAN (OD)
Entity Type:Individual
Prefix:DR
First Name:JILL
Middle Name:SUSAN
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15933 CLAYTON RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63011-2172
Mailing Address - Country:US
Mailing Address - Phone:636-200-4393
Mailing Address - Fax:636-527-0838
Practice Address - Street 1:5101 N DAVIS HWY
Practice Address - Street 2:STE A
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32503-2040
Practice Address - Country:US
Practice Address - Phone:850-479-7379
Practice Address - Fax:850-497-6219
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2017-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC2969152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL20775OtherFLORIDA BLUE
FL20775UOtherMEDICARE PIN
FLP00412350OtherRR MEDICARE
FL20775OtherFLORIDA BLUE
FL20775UOtherMEDICARE PIN