Basic Information
| Provider Information | |||||||||
| NPI: | 1851726384 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KAUDERMAN | ||||||||
| FirstName: | ANNA | ||||||||
| MiddleName: | FRANCES | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1620 BROWNING RD | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292106924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037988642 | ||||||||
| FaxNumber: | 8037980422 | ||||||||
| Practice Location | |||||||||
| Address1: | 627 S HOUSTON LAKE RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | WARNER ROBINS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310889079 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4783220009 | ||||||||
| FaxNumber: | 4783336979 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/03/2013 | ||||||||
| LastUpdateDate: | 10/09/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OPC4832 | FL | N | Eye and Vision Services Providers | Optometrist | 152W00000X | 1938 | SC | N | Eye and Vision Services Providers | Optometrist | 152W00000X | OPT003123 | GA | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | D19380 | 05 | SC | MEDICAID |