Provider Demographics
NPI:1386716157
Name:OPHTHALMIC PLASTIC AND RECONSTRUCTIVE SURGERY, P.A.
Entity type:Organization
Organization Name:OPHTHALMIC PLASTIC AND RECONSTRUCTIVE SURGERY, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:P
Authorized Official - Last Name:CARROLL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:612-325-0317
Mailing Address - Street 1:4887 E LAKE HARRIET BLVD
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55419-5222
Mailing Address - Country:US
Mailing Address - Phone:612-325-0317
Mailing Address - Fax:
Practice Address - Street 1:4887 E LAKE HARRIET BLVD
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55419-5222
Practice Address - Country:US
Practice Address - Phone:612-325-0317
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2010-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN799174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN122169D805OtherUCARE MINNESOTA
SD7787270Medicaid
MN95322OtherHEALTH PARTNERS
ND16176Medicaid
MN0802163OtherMEDICA
MN26128OPOtherBLUE CROSS BLUE SHIELD MN
MN031010700Medicaid
WI31260500Medicaid
WI31260500Medicaid
GACP2456Medicare PIN
ND16176Medicaid
GACP2368Medicare PIN