Provider Demographics
NPI:1104146265
Name:MINNESOTA EYE CONSULTANTS, PA
Entity type:Organization
Organization Name:MINNESOTA EYE CONSULTANTS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:L
Authorized Official - Last Name:WILDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-567-6143
Mailing Address - Street 1:9801 DUPONT AVE S
Mailing Address - Street 2:SUITE 425
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55431-3100
Mailing Address - Country:US
Mailing Address - Phone:952-888-5800
Mailing Address - Fax:
Practice Address - Street 1:11091 ULYSSES ST NE
Practice Address - Street 2:SUITE 300
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55434-4237
Practice Address - Country:US
Practice Address - Phone:952-888-5800
Practice Address - Fax:763-421-8297
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-10
Last Update Date:2017-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
291U00000X
MN31920207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No291U00000XLaboratoriesClinical Medical LaboratoryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN24D2023184OtherCLIA
MNC02541Medicare PIN