Provider Demographics
NPI:1942786249
Name:ANDERSON, ALYSSA K (OD)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:K
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 1:4600 - 30TH STREET
Mailing Address - Street 2:
Mailing Address - City:ROCK ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:61201-7038
Mailing Address - Country:US
Mailing Address - Phone:309-788-5524
Mailing Address - Fax:309-788-9550
Practice Address - Street 1:4600 - 30TH STREET
Practice Address - Street 2:
Practice Address - City:ROCK ISLAND
Practice Address - State:IL
Practice Address - Zip Code:61201-7038
Practice Address - Country:US
Practice Address - Phone:309-788-5524
Practice Address - Fax:309-788-9550
Is Sole Proprietor?:No
Enumeration Date:2018-07-19
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046011212152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist