1366422735 NPI number — DR. JILL A ANDERSON O.D.

Table of content: DR. JILL A ANDERSON O.D. (NPI 1366422735)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366422735 NPI number — DR. JILL A ANDERSON O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANDERSON
Provider First Name:
JILL
Provider Middle Name:
A
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1366422735
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/08/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1123 BERLIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WAUPACA
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54981-1920
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-340-0496
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1000 N WESTHILL BLVD
Provider Second Line Business Practice Location Address:
OPTICAL
Provider Business Practice Location Address City Name:
APPLETON
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54914-5792
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-733-7804
Provider Business Practice Location Address Fax Number:
920-733-7940
Provider Enumeration Date:
01/20/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  2651-035 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)