Provider Demographics
NPI:1619964855
Name:ANDERSON, JEFFREY B (OD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:B
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:PO BOX 188
Mailing Address - Street 2:
Mailing Address - City:MONTEVIDEO
Mailing Address - State:MN
Mailing Address - Zip Code:56265-0188
Mailing Address - Country:US
Mailing Address - Phone:320-269-8182
Mailing Address - Fax:320-269-5868
Practice Address - Street 1:602 LEGION DR
Practice Address - Street 2:
Practice Address - City:MONTEVIDEO
Practice Address - State:MN
Practice Address - Zip Code:56265-1709
Practice Address - Country:US
Practice Address - Phone:320-269-8182
Practice Address - Fax:320-269-5868
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-03
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1614152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
419000354OtherHUMANA
419000354OtherUNICARE
MN44020ANOtherBLUE CROSS AND BLUE SHIEL
MN715581024800OtherPREFERRED ONE
2214650OtherMEDICA
HP21877OtherHEALTH PARTNERS
MN334723100Medicaid
MN5C004ANOtherBCBS OPTICAL ONLY
MN5C004ANOtherBCBS OPTICAL ONLY
419000354OtherUNICARE
410009076Medicare ID - Type UnspecifiedRAILROAD MEDICARE
MN334723100Medicaid