Provider Demographics
NPI:1750342564
Name:ANDERSON, STUART I (OD)
Entity type:Individual
Prefix:DR
First Name:STUART
Middle Name:I
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 1:1205 WATERSIDE CV APT 32
Mailing Address - Street 2:
Mailing Address - City:COTTONWOOD HEIGHTS
Mailing Address - State:UT
Mailing Address - Zip Code:84047-4273
Mailing Address - Country:US
Mailing Address - Phone:801-870-5056
Mailing Address - Fax:
Practice Address - Street 1:6095 FASHION BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-7397
Practice Address - Country:US
Practice Address - Phone:801-262-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2010-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT56972519934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000059712Medicare PIN
UTV01218Medicare UPIN