Provider Demographics
NPI:1972814341
Name:ANDERSON, ELIZABETH BENNETT (OD)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:BENNETT
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 1:365 6TH ST
Mailing Address - Street 2:
Mailing Address - City:HOLLISTER
Mailing Address - State:CA
Mailing Address - Zip Code:95023-3834
Mailing Address - Country:US
Mailing Address - Phone:831-637-5536
Mailing Address - Fax:831-637-7601
Practice Address - Street 1:365 6TH ST
Practice Address - Street 2:
Practice Address - City:HOLLISTER
Practice Address - State:CA
Practice Address - Zip Code:95023-3834
Practice Address - Country:US
Practice Address - Phone:831-637-5536
Practice Address - Fax:831-637-7601
Is Sole Proprietor?:No
Enumeration Date:2010-06-30
Last Update Date:2013-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10025T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU75313Medicare UPIN
CAEL883ZMedicare PIN