Provider Demographics
NPI:1982702114
Name:ANDERSON, KELLY D (OD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:D
Last Name:ANDERSON
Suffix:
Gender:F
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:PO BOX 61199
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33906-1199
Mailing Address - Country:US
Mailing Address - Phone:239-418-0262
Mailing Address - Fax:239-274-0773
Practice Address - Street 1:1201 PIPER BLVD
Practice Address - Street 2:SUITE 22
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34110-1380
Practice Address - Country:US
Practice Address - Phone:239-734-3877
Practice Address - Fax:239-734-3879
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2019-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 3770152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL620851700Medicaid
FL23001OtherBCBS NUMBER
FLOPC3770OtherMEDICAL LICENSE