1346291630 NPI number — DOFFIN FAMILY EYE CARE PA

Table of content: (NPI 1346291630)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346291630 NPI number — DOFFIN FAMILY EYE CARE PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DOFFIN FAMILY EYE CARE PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1346291630
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/25/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4750 WASHINGTON SQ
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WHITE BEAR LAKE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55110-3257
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-429-3379
Provider Business Mailing Address Fax Number:
651-429-8681

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4750 WASHINGTON SQ
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WHITE BEAR LAKE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55110-3257
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-429-3379
Provider Business Practice Location Address Fax Number:
651-429-8681
Provider Enumeration Date:
05/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
OLUFSON
Authorized Official First Name:
JULIE
Authorized Official Middle Name:
Authorized Official Title or Position:
INSURANCE MANAGER
Authorized Official Telephone Number:
651-429-3379

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 27679RU . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 105474 . This is a "UCARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 2200089 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 2117748 . This is a "MEDICA-DME" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 29623WH . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 307262200 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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