Provider Demographics
NPI:1043280555
Name:ANDERSON, KENYON B (OD)
Entity type:Individual
Prefix:DR
First Name:KENYON
Middle Name:B
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 1:252 W MAIN ST STE C
Mailing Address - Street 2:
Mailing Address - City:SANTAQUIN
Mailing Address - State:UT
Mailing Address - Zip Code:84655-7086
Mailing Address - Country:US
Mailing Address - Phone:801-609-2020
Mailing Address - Fax:
Practice Address - Street 1:252 W MAIN ST STE C
Practice Address - Street 2:
Practice Address - City:SANTAQUIN
Practice Address - State:UT
Practice Address - Zip Code:84655
Practice Address - Country:US
Practice Address - Phone:801-609-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2019-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-100087152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID287790Medicare ID - Type UnspecifiedMEDICAIRE REFERENCE NUMBE