Provider Demographics
NPI:1356364236
Name:ANDERSON, PAUL S (OD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:S
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 1:310 8TH AVE NW STE 503
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:SD
Mailing Address - Zip Code:57401-2369
Mailing Address - Country:US
Mailing Address - Phone:605-225-2020
Mailing Address - Fax:605-725-2614
Practice Address - Street 1:2701 FOX RUN PKWY
Practice Address - Street 2:
Practice Address - City:YANKTON
Practice Address - State:SD
Practice Address - Zip Code:57078-5350
Practice Address - Country:US
Practice Address - Phone:605-665-7762
Practice Address - Fax:605-725-2614
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2017-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD402152W00000X
SD123152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD9200817Medicaid
NE46036358113Medicaid
SD9200817Medicaid
SDT66666Medicare UPIN
NE271194Medicare PIN