1689777179 NPI number — DR. PAUL PRESTON O.D.

Table of content: DR. PAUL PRESTON O.D. (NPI 1689777179)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689777179 NPI number — DR. PAUL PRESTON O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PRESTON
Provider First Name:
PAUL
Provider Middle Name:
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:
1689777179
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/12/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
385 W MARKET
Provider Second Line Business Mailing Address:
MALL OF AMERICA
Provider Business Mailing Address City Name:
BLOOMINGTON
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55425-5523
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-854-4500
Provider Business Mailing Address Fax Number:
952-858-8525

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
385 W MARKET
Provider Second Line Business Practice Location Address:
MALL OF AMERICA
Provider Business Practice Location Address City Name:
BLOOMINGTON
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55425-5523
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-854-4500
Provider Business Practice Location Address Fax Number:
952-858-8525
Provider Enumeration Date:
09/07/2006

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:  MN2559 , 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: 299K8PR . This is a "MOA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: MN2559 . This is a "EYEMED" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 183M3PR . This is a "BCBS/MN ST LOUIS PK" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 2200266 . This is a "MEDICA/UNITED HEALTH CARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 2219201 . This is a "AMERICA'S PPO" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 2202539 . This is a "MEDICA/UNITED HEALTH CARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 370517000 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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