Provider Demographics
NPI:1629040134
Name:ANDERSON, MIRIAM LORRAINE (OD)
Entity Type:Individual
Prefix:
First Name:MIRIAM
Middle Name:LORRAINE
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 1:221 NW MCNARY CT
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64086-4011
Mailing Address - Country:US
Mailing Address - Phone:816-524-8900
Mailing Address - Fax:816-525-2042
Practice Address - Street 1:221 NW MCNARY CT
Practice Address - Street 2:
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64086-4011
Practice Address - Country:US
Practice Address - Phone:816-524-8900
Practice Address - Fax:816-525-2042
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT02626152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP00096424OtherRAILROAD MEDICARE
MO25420027OtherBLUECROSS BLUESHIELD OF KANSAS CITY