Provider Demographics
NPI:1881678415
Name:ANDERSON, PAUL EDWARD (OD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:EDWARD
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 1:600 SW 10TH ST STE 104
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34471-0200
Mailing Address - Country:US
Mailing Address - Phone:352-629-7509
Mailing Address - Fax:352-867-5652
Practice Address - Street 1:600 SW 10TH ST STE 104
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34471-0200
Practice Address - Country:US
Practice Address - Phone:352-629-7509
Practice Address - Fax:352-867-5652
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2008-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2261152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL620636100Medicaid
20161Medicare PIN
FL620636100Medicaid
FL4278340001Medicare NSC