Basic Information
| Provider Information | |||||||||
| NPI: | 1598881534 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | MITCHELL | ||||||||
| MiddleName: | RAY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1950 OLD GALLOWS RD STE 520 | ||||||||
| Address2: | |||||||||
| City: | VIENNA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221823970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7038478899 | ||||||||
| FaxNumber: | 5712236780 | ||||||||
| Practice Location | |||||||||
| Address1: | 4520 S HARVARD AVE STE 135 | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741352916 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187459662 | ||||||||
| FaxNumber: | 9187459663 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2007 | ||||||||
| LastUpdateDate: | 11/01/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 11/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152WC0802X | 1069 | OK | N | Eye and Vision Services Providers | Optometrist | Corneal and Contact Management | 152W00000X | 1069 | OK | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 112326 | 01 | OK | EYEMED | OTHER | 3518 | 01 | OK | SUPERIOR VISION | OTHER | ANDE23832 | 01 | OK | SPECTERA | OTHER | 1598881534 | 01 | OK | BCBS OF OKLAHOMA | OTHER | 274812801 | 01 | OK | FEDERAL ID | OTHER | 9184554545 | 01 | OK | VSP | OTHER | 9745 | 01 | OK | AVESIS | OTHER |