Provider Demographics
NPI:1740345776
Name:ANDERSON, ROGER ALLAN (OD)
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:ALLAN
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 1:1405 4TH ST SW
Mailing Address - Street 2:STE 2
Mailing Address - City:SIDNEY
Mailing Address - State:MT
Mailing Address - Zip Code:59270-3515
Mailing Address - Country:US
Mailing Address - Phone:406-488-2705
Mailing Address - Fax:406-488-2713
Practice Address - Street 1:1405 4TH ST SW
Practice Address - Street 2:WEST SIDE PROFESSIONAL CENTER STE 2
Practice Address - City:SIDNEY
Practice Address - State:MT
Practice Address - Zip Code:59270-3515
Practice Address - Country:US
Practice Address - Phone:406-488-2705
Practice Address - Fax:406-488-2713
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT414152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0480857Medicaid
MT27110OtherBLUE CROSS BLUE SHIELD
MT0480857Medicaid
T92603Medicare UPIN