1619918935 NPI number — DR. JILL SUSAN ANDERSON O.D.

Table of content: DR. JILL SUSAN ANDERSON O.D. (NPI 1619918935)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619918935 NPI number — DR. JILL SUSAN ANDERSON O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANDERSON
Provider First Name:
JILL
Provider Middle Name:
SUSAN
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:
1619918935
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/03/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15933 CLAYTON RD
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
BALLWIN
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63011-2172
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
636-200-4393
Provider Business Mailing Address Fax Number:
636-527-0838

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5101 N DAVIS HWY
Provider Second Line Business Practice Location Address:
STE A
Provider Business Practice Location Address City Name:
PENSACOLA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32503-2040
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-479-7379
Provider Business Practice Location Address Fax Number:
850-497-6219
Provider Enumeration Date:
06/09/2006

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:  OPC2969 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 20775 . This is a "FLORIDA BLUE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 20775U . This is a "MEDICARE PIN" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: P00412350 . This is a "RR MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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