1205863693 NPI number — DR. SANDRA K DOLPHIN O.D.

Table of content: DR. SANDRA K DOLPHIN O.D. (NPI 1205863693)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205863693 NPI number — DR. SANDRA K DOLPHIN O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DOLPHIN
Provider First Name:
SANDRA
Provider Middle Name:
K
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205863693
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/03/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
213 SOUTH ADAMS STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ST CROIX FALLS
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54024
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-483-3259
Provider Business Mailing Address Fax Number:
715-483-5136

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
213 S ADAMS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST CROIX FALLS
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54024
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-483-3259
Provider Business Practice Location Address Fax Number:
715-483-5136
Provider Enumeration Date:
06/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  2589-035 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 22-02486 . This is a "MEDICA/SELECT CARE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: HP26431 . This is a "HEALTH PARTNERS" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 97969-1007552 . This is a "PREFERRED ONE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 5173080001 . This is a "DMEPOS" identifier . This identifiers is of the category "OTHER".
  • Identifier: P00175525 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 38623500 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 538722180 . This is a "MN MA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 270L2DO . This is a "BCBS MN" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 511297 . This is a "NVA" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".




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