Provider Demographics
NPI:1760466098
Name:ANDERSON, JEFFREY CRAIG (OD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:CRAIG
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 1:621 STORY ST
Mailing Address - Street 2:
Mailing Address - City:BOONE
Mailing Address - State:IA
Mailing Address - Zip Code:50036-4242
Mailing Address - Country:US
Mailing Address - Phone:515-432-2973
Mailing Address - Fax:
Practice Address - Street 1:621 STORY ST
Practice Address - Street 2:
Practice Address - City:BOONE
Practice Address - State:IA
Practice Address - Zip Code:50036-4242
Practice Address - Country:US
Practice Address - Phone:515-432-2973
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1854152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA2259416Medicaid
410047847OtherRRM RAILROAD MEDICARE
4512050001OtherCIGNA/DMERC
IA51176OtherBLUE CROSS/BLUE SHIELD
T01469Medicare UPIN
IAI4690Medicare PIN