Provider Demographics
NPI:1770611477
Name:JEFFREY L. ANDERSON, O.D.
Entity type:Organization
Organization Name:JEFFREY L. ANDERSON, O.D.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:LEON
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:507-282-7121
Mailing Address - Street 1:1608 1ST ST NW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55901-0318
Mailing Address - Country:US
Mailing Address - Phone:507-282-7121
Mailing Address - Fax:
Practice Address - Street 1:1608 1ST ST NW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55901-0318
Practice Address - Country:US
Practice Address - Phone:507-282-7121
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2665152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN605K3LIOtherBLUE CROSS BLUE SHIELD
MN916891050630OtherPREFERRED ONE
MN031217700Medicaid
MN22-00464OtherMEDICA
MN39797WEOtherBLUE CROSS BLUE SHIELD
MNHP77005OtherHEALTHPARTNERS
MN763132000Medicaid
MN628A8SIOtherBLUE CROSS BLUE SHIELD
MN766571021763OtherPREFERRED ONE
MNHP52030OtherHEALTHPARTNERS
MN108909OtherHEALTHPARTNERS
MN131927OtherUCARE
MN138801OtherUCARE
MN6C464ANOtherBLUE CROSS BLUE SHIELD
MN39797WEOtherBLUE CROSS BLUE SHIELD
MNHP77005OtherHEALTHPARTNERS
MN=========OtherMAYO MANAGEMENT SERVICES
MN031217700Medicaid
MN1226370002Medicare NSC
MN410002771Medicare PIN