Provider Demographics
NPI:1851404628
Name:ANDERSON, KERRY SCOT (OD)
Entity Type:Individual
Prefix:DR
First Name:KERRY
Middle Name:SCOT
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 1:21078 JEWEL CT
Mailing Address - Street 2:
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-4038
Mailing Address - Country:US
Mailing Address - Phone:909-628-8860
Mailing Address - Fax:909-628-6120
Practice Address - Street 1:14335 PIPELINE AVE
Practice Address - Street 2:
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710-5642
Practice Address - Country:US
Practice Address - Phone:909-628-8860
Practice Address - Fax:909-628-6120
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2012-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 9775 TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0097750Medicaid
CAGT040YMedicare PIN
CAGT040ZMedicare PIN
U60104Medicare UPIN