1003922030 NPI number — DR. ROY WILLIAM BACKUS O.D.

Table of content: DR. ROY WILLIAM BACKUS O.D. (NPI 1003922030)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003922030 NPI number — DR. ROY WILLIAM BACKUS O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BACKUS
Provider First Name:
ROY
Provider Middle Name:
WILLIAM
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
M

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:
1003922030
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
38050 JEFFERY AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTH BRANCH
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55056-5908
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-237-0330
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 12TH ST SW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FOREST LAKE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55025-1482
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-464-9767
Provider Business Practice Location Address Fax Number:
651-464-9062
Provider Enumeration Date:
08/22/2006

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:  2520 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 22-14902 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 48705 . This is a "DAVIS VISION" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 4100006627 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6C258BA . This is a "BCBS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 152144 . This is a "COLE VISION" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 410042867 . This is a "RAILROAD PROVIDER #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 212298 . This is a "BCBS OPTI CHOICE #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 12060 . This is a "SPECTERA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 489437500 . This is a "MN HEALTH CARE PROVIDER #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 71-0415188 . This is a "SUPERIOR VISION" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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