Provider Demographics
NPI:1104975762
Name:DOCKTER, CHAD R (OD)
Entity type:Individual
Prefix:DR
First Name:CHAD
Middle Name:R
Last Name:DOCKTER
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 1:1464 WHITE OAK DR.
Mailing Address - Street 2:
Mailing Address - City:CHASKA
Mailing Address - State:MN
Mailing Address - Zip Code:55318
Mailing Address - Country:US
Mailing Address - Phone:952-466-3937
Mailing Address - Fax:952-466-3936
Practice Address - Street 1:TARGET OPTICAL
Practice Address - Street 2:8225 FLYING CLOUD DRIVE
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55344
Practice Address - Country:US
Practice Address - Phone:952-563-0247
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2012-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2439152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNU46998Medicare UPIN
MN419000231Medicare ID - Type Unspecified