Provider Demographics
NPI:1770031452
Name:ANDERSON, JOHN (OD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
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 1:815 W COLLEGE ST STE B
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-5029
Mailing Address - Country:US
Mailing Address - Phone:406-587-8333
Mailing Address - Fax:406-587-8369
Practice Address - Street 1:815 W COLLEGE ST STE B
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-5029
Practice Address - Country:US
Practice Address - Phone:406-587-8333
Practice Address - Fax:406-587-8369
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-12
Last Update Date:2017-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTOPT-OPT-LIC-2799152W00000X
IDODP-100378152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist