Provider Demographics
NPI:1669442661
Name:ANDERSON, DUSTIN CLARK (OD)
Entity Type:Individual
Prefix:DR
First Name:DUSTIN
Middle Name:CLARK
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 1:5324 HENRY DOREN PT
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80924-5300
Mailing Address - Country:US
Mailing Address - Phone:719-649-5634
Mailing Address - Fax:
Practice Address - Street 1:7238 N ACADEMY BLVD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920
Practice Address - Country:US
Practice Address - Phone:719-292-9991
Practice Address - Fax:719-649-5634
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2019-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2952152W00000X
TX05890152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist