Provider Demographics
NPI:1194717298
Name:GRUDEM, BRIAN DWIGHT (OD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:DWIGHT
Last Name:GRUDEM
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 1:4720 WHITE BEAR PKWY
Mailing Address - Street 2:
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-3336
Mailing Address - Country:US
Mailing Address - Phone:651-426-2747
Mailing Address - Fax:651-426-9838
Practice Address - Street 1:4720 WHITE BEAR PKWY
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-3336
Practice Address - Country:US
Practice Address - Phone:651-426-2747
Practice Address - Fax:651-426-9838
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLD1732000152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNP00124841OtherMEDICARE RAILROAD RETIREM
MN965400656001OtherPREFERRED ONE
MN0N456GROtherBLUE CROSS BLUE SHIELD
MNHP29577OtherHEALTH PARTNERS
MN22-02690OtherMEDICA
MN22-02779OtherMEDICA
MN22-02690OtherMEDICA