Provider Demographics
NPI:1801380753
Name:ANDERSON, CORRIE (OD)
Entity Type:Individual
Prefix:
First Name:CORRIE
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:CORRIE
Other - Middle Name:
Other - Last Name:POLLOCK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:16409 SOUTHPARK DR
Mailing Address - Street 2:
Mailing Address - City:WESTFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46074-8470
Mailing Address - Country:US
Mailing Address - Phone:317-896-5005
Mailing Address - Fax:317-896-5335
Practice Address - Street 1:16409 SOUTHPARK DR
Practice Address - Street 2:
Practice Address - City:WESTFIELD
Practice Address - State:IN
Practice Address - Zip Code:46074-8470
Practice Address - Country:US
Practice Address - Phone:317-896-5005
Practice Address - Fax:317-896-5335
Is Sole Proprietor?:No
Enumeration Date:2018-06-14
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901005147152W00000X
IN18004183A152WV0400X, 152WP0200X, 152W00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics