Provider Demographics
NPI:1205991692
Name:ANDERSON, JEREMY R (OD)
Entity type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:R
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 12TH AVE E
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:MN
Mailing Address - Zip Code:56308-2528
Mailing Address - Country:US
Mailing Address - Phone:320-763-4321
Mailing Address - Fax:320-763-6921
Practice Address - Street 1:120 12TH AVE E
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308-2528
Practice Address - Country:US
Practice Address - Phone:320-763-4321
Practice Address - Fax:320-763-6921
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2725152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN140844OtherUCARE
MN43F52ANOtherBCBS
MNHP31873OtherHEALTH PARTNERS
MN410046064OtherRAILROAD MEDICARE
MN1027401OtherPREFERRED ONE
MN23375OtherAVESIS
MN263685900Medicaid
MN030701053OtherPRIMEWEST
MN22-01217OtherMEDICA
MNU76473Medicare UPIN
MN410001638Medicare PIN