Provider Demographics
NPI:1710975479
Name:ANDERSON, KRISTA MARIE (OD)
Entity Type:Individual
Prefix:DR
First Name:KRISTA
Middle Name:MARIE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:KRISTA
Other - Middle Name:MARIE
Other - Last Name:FREISMUTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:45900 RIVERVIEW CT
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48044-4220
Mailing Address - Country:US
Mailing Address - Phone:586-412-6964
Mailing Address - Fax:313-881-9380
Practice Address - Street 1:19637 MACK AVE
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE WOODS
Practice Address - State:MI
Practice Address - Zip Code:48236-2535
Practice Address - Country:US
Practice Address - Phone:313-881-6622
Practice Address - Fax:313-881-9380
Is Sole Proprietor?:No
Enumeration Date:2005-10-07
Last Update Date:2009-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004058152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIU89619Medicare UPIN
MION55850002Medicare ID - Type Unspecified