Provider Demographics
NPI:1619964459
Name:ANDERSON, JAMES STANLEY (OD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:STANLEY
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 1:16550 W 78TH ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55346-4315
Mailing Address - Country:US
Mailing Address - Phone:952-934-6926
Mailing Address - Fax:
Practice Address - Street 1:16550 W 78TH ST
Practice Address - Street 2:SUITE A
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55346-4315
Practice Address - Country:US
Practice Address - Phone:952-934-6926
Practice Address - Fax:952-934-3402
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2012-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1637152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
410000116Medicare ID - Type Unspecified
T39472Medicare UPIN