1275626731 NPI number — DR. BYRON K FLECK O.D.

Table of content: DR. BYRON K FLECK O.D. (NPI 1275626731)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275626731 NPI number — DR. BYRON K FLECK O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FLECK
Provider First Name:
BYRON
Provider Middle Name:
K
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:
1275626731
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/13/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8664 EVERGREEN LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COTTON
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55724-8109
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-482-3284
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4740 MALL DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HERMANTOWN
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55811
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-727-1204
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/02/2006

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: 152WC0802X , with the licence number:  2733 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 152WC0802X , with the licence number: 2788-035 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: B25851028756 . This is a "PREFERRED ONE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 16525 . This is a "SPECTERA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 37832 . This is a "AVESIS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 647819 . This is a "PA BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 128886 . This is a "U-CARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 22-03394 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 22-03395 . This is a "MEDICA" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 647819 . This is a "BCBS PA" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: B25861028756 . This is a "PREFERRED ONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 43076 . This is a "SPECTERA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 37024 . This is a "AVESIS" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 53M11FL . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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