Provider Demographics
NPI:1720196553
Name:ANDERSON, TODD G (OD)
Entity Type:Individual
Prefix:DR
First Name:TODD
Middle Name:G
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 1:433 HELAMAN RD
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362
Mailing Address - Country:US
Mailing Address - Phone:509-301-5452
Mailing Address - Fax:
Practice Address - Street 1:1700 SE MEADOWBROOK BLVD
Practice Address - Street 2:
Practice Address - City:COLLEGE PLACE
Practice Address - State:WA
Practice Address - Zip Code:99324-1798
Practice Address - Country:US
Practice Address - Phone:509-525-3700
Practice Address - Fax:509-525-3748
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2563ATI152W00000X
WAOD00003258152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAU62889Medicare UPIN