1063601128 NPI number — MRS. PATRICIA ANDERSON O.D.

Table of content: MRS. PATRICIA ANDERSON O.D. (NPI 1063601128)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063601128 NPI number — MRS. PATRICIA ANDERSON O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANDERSON
Provider First Name:
PATRICIA
Provider Middle Name:
Provider Name Prefix Text:
MRS.
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:
1063601128
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/27/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1950 OLD GALLOWS RD
Provider Second Line Business Mailing Address:
SUITE 520
Provider Business Mailing Address City Name:
VIENNA
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22182-3990
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-847-8899
Provider Business Mailing Address Fax Number:
703-991-0514

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2003 COMMERCE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KINGSLAND
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31548-6767
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-882-3040
Provider Business Practice Location Address Fax Number:
912-882-3786
Provider Enumeration Date:
10/15/2007

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: 152WL0500X , with the licence number:  WY222T , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X , with the licence number: OPT002807 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 003150919A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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