Provider Demographics
NPI:1609833227
Name:ANDERSON, EDWIN GWIN (OD)
Entity type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:GWIN
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:PO BOX 31
Mailing Address - Street 2:
Mailing Address - City:DRESDEN
Mailing Address - State:TN
Mailing Address - Zip Code:38225-0031
Mailing Address - Country:US
Mailing Address - Phone:731-364-2150
Mailing Address - Fax:731-364-5157
Practice Address - Street 1:113 E LOCUST ST
Practice Address - Street 2:
Practice Address - City:DRESDEN
Practice Address - State:TN
Practice Address - Zip Code:38225-1440
Practice Address - Country:US
Practice Address - Phone:731-364-2150
Practice Address - Fax:731-364-5157
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2014-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNODT643152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNODT643OtherSTATE LICENSE NUMBER
TNODT643OtherSTATE LICENSE NUMBER
TNU23769Medicare UPIN
TN3594040Medicare PIN
TN3594049Medicare PIN