Provider Demographics
NPI:1821640517
Name:ANDERSON, DUSTIN WILLIAM
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:WILLIAM
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 207158
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75320-7158
Mailing Address - Country:US
Mailing Address - Phone:636-200-4393
Mailing Address - Fax:
Practice Address - Street 1:9082 OVERLAND PLZ
Practice Address - Street 2:
Practice Address - City:OVERLAND
Practice Address - State:MO
Practice Address - Zip Code:63114-6122
Practice Address - Country:US
Practice Address - Phone:314-227-1132
Practice Address - Fax:314-227-1133
Is Sole Proprietor?:No
Enumeration Date:2019-07-12
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019021861152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist