Provider Demographics
NPI:1356436661
Name:ANDERSON, BRIAN (OD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:
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 1:3200 SOARING GULLS DRIVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89129-2198
Mailing Address - Country:US
Mailing Address - Phone:702-645-3211
Mailing Address - Fax:702-645-8878
Practice Address - Street 1:3200 SOARING GULLS DRIVE
Practice Address - Street 2:SUITE 104
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89129-2198
Practice Address - Country:US
Practice Address - Phone:702-645-3211
Practice Address - Fax:702-645-8878
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2023-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOPT-000807152W00000X
COOPT.0003743152W00000X
NVNV285152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1356436661Medicaid
NVU25000Medicare UPIN