Provider Demographics
NPI:1699827543
Name:ANDERSEN, JOHN MICHAEL (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MICHAEL
Last Name:ANDERSEN
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 1:11121 W 95TH ST
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66214-1824
Mailing Address - Country:US
Mailing Address - Phone:913-492-7728
Mailing Address - Fax:913-492-5217
Practice Address - Street 1:11121 W 95TH ST
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66214
Practice Address - Country:US
Practice Address - Phone:913-492-7728
Practice Address - Fax:913-492-5217
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE773152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
06749OtherBCBS
06749OtherBCBS