Provider Demographics
NPI:1609984673
Name:TUSCALOOSA OPTICAL DISPENSARY, INC.
Entity type:Organization
Organization Name:TUSCALOOSA OPTICAL DISPENSARY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:ANDERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-562-8177
Mailing Address - Street 1:5121 UNIVERSITY BLVD E
Mailing Address - Street 2:
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35404-5207
Mailing Address - Country:US
Mailing Address - Phone:205-562-8177
Mailing Address - Fax:205-554-7968
Practice Address - Street 1:5121 UNIVERSITY BLVD E
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35404-5207
Practice Address - Country:US
Practice Address - Phone:205-562-8177
Practice Address - Fax:205-554-7968
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2010-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3693332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL00059308Medicaid
AL051059308OtherBLUE CROSS BLUE SHIELD
AL0256440001Medicare NSC