Provider Demographics
NPI:1366529547
Name:PERSZYK, JOHN JOSEPH (OD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:JOSEPH
Last Name:PERSZYK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:12577 WAYZATA BLVD
Mailing Address - Street 2:PEARLE EXPRESS / RIDGEDALE
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55305-1938
Mailing Address - Country:US
Mailing Address - Phone:952-546-4414
Mailing Address - Fax:952-541-0831
Practice Address - Street 1:12577 WAYZATA BLVD
Practice Address - Street 2:PEARLE EXPRESS / RIDGEDALE
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-1938
Practice Address - Country:US
Practice Address - Phone:952-546-4414
Practice Address - Fax:952-541-0831
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2005152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNT74867Medicare UPIN