Provider Demographics
NPI:1891782710
Name:ANDERSON, DENNIS LELAND (OD)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:LELAND
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:DR
Other - First Name:DENNIS
Other - Middle Name:LELAND
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:100 E 12TH ST
Mailing Address - Street 2:
Mailing Address - City:JEFFERSONVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47130-3834
Mailing Address - Country:US
Mailing Address - Phone:812-288-7179
Mailing Address - Fax:
Practice Address - Street 1:100 E 12TH ST
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130-3834
Practice Address - Country:US
Practice Address - Phone:812-288-7179
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-05
Last Update Date:2010-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001580AB152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
INT 69216Medicare UPIN
IN123270Medicare PIN
IN0161480001Medicare NSC