Provider Demographics
NPI:1063441830
Name:ACKERMANN, MICHAEL D (OD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:D
Last Name:ACKERMANN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 W CENTER ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:MN
Mailing Address - Zip Code:55041
Mailing Address - Country:US
Mailing Address - Phone:651-345-3039
Mailing Address - Fax:651-345-3506
Practice Address - Street 1:117 W CENTER ST
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:MN
Practice Address - Zip Code:55041
Practice Address - Country:US
Practice Address - Phone:651-345-3039
Practice Address - Fax:651-345-3506
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-02
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2672152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN455515500Medicaid
MN80G78ACOtherBLUE CROSS BLUE SHIELD
MNU73175Medicare UPIN
MN1063441830Medicare NSC
MN410002610Medicare ID - Type Unspecified