Provider Demographics
NPI:1720282775
Name:ANDERSON, BENJAMIN FREEMAN JR (OD)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:FREEMAN
Last Name:ANDERSON
Suffix:JR
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 1:5062 W ATLANTIC AVE
Mailing Address - Street 2:
Mailing Address - City:DELRAY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33484-8129
Mailing Address - Country:US
Mailing Address - Phone:561-498-8884
Mailing Address - Fax:561-498-7878
Practice Address - Street 1:5062 W ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:DELRAY BEACH
Practice Address - State:FL
Practice Address - Zip Code:33484-8129
Practice Address - Country:US
Practice Address - Phone:561-498-8884
Practice Address - Fax:561-498-7878
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-13
Last Update Date:2010-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 3866152W00000X
SC1276152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCU96402Medicare UPIN