Provider Demographics
NPI:1891837977
Name:ANDERSON, KATHY (OD)
Entity Type:Individual
Prefix:DR
First Name:KATHY
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 TENHOLDER PLAZA
Mailing Address - Street 2:SOUTH COUNTY CENTERWAY
Mailing Address - City:ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63129
Mailing Address - Country:US
Mailing Address - Phone:314-845-2300
Mailing Address - Fax:314-845-2343
Practice Address - Street 1:122 TENHOLDER PLAZA
Practice Address - Street 2:SOUTH COUNTY CENTERWAY
Practice Address - City:ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63129
Practice Address - Country:US
Practice Address - Phone:314-845-2300
Practice Address - Fax:314-845-2343
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2010-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000161866152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOU81823Medicare UPIN
MA1595028Medicare PIN