Provider Demographics
NPI:1821160102
Name:ANDERSON, RICHARD B (OD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:B
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 1:3900 E MEXICO AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80210-3941
Mailing Address - Country:US
Mailing Address - Phone:720-524-1001
Mailing Address - Fax:720-524-1121
Practice Address - Street 1:3900 E MEXICO AVE STE 102
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80210-3941
Practice Address - Country:US
Practice Address - Phone:720-524-1001
Practice Address - Fax:720-524-1121
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2016-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCO 1350152W00000X
COOPV.0000003152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO08012494Medicaid
COCH0213Medicare UPIN