Provider Demographics
NPI:1942262621
Name:ANDERSON, JEREMY PATRICK (OD)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:PATRICK
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 1:118 MUSGROVE ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:SC
Mailing Address - Zip Code:29325-2350
Mailing Address - Country:US
Mailing Address - Phone:864-833-5555
Mailing Address - Fax:
Practice Address - Street 1:227 E BLACKSTOCK RD
Practice Address - Street 2:SUITE 200
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29301-2632
Practice Address - Country:US
Practice Address - Phone:864-585-7807
Practice Address - Fax:864-585-8272
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1321152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAA05988525OtherPROVIDER ID NUMBER
SCD13215Medicaid
SCV011358525Medicare UPIN
SCAA05988525OtherPROVIDER ID NUMBER
SCD13215Medicaid