Provider Demographics
NPI:1457563827
Name:MINNESOTA VISION OUTREACH, INC
Entity type:Organization
Organization Name:MINNESOTA VISION OUTREACH, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:WOLFSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:763-585-8414
Mailing Address - Street 1:9905 45TH AVENUE NORTH
Mailing Address - Street 2:SUITE 110
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55422-3315
Mailing Address - Country:US
Mailing Address - Phone:763-595-8414
Mailing Address - Fax:763-595-8438
Practice Address - Street 1:9905 45TH AVENUE NORTH
Practice Address - Street 2:SUITE 110
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55422-3315
Practice Address - Country:US
Practice Address - Phone:763-595-8414
Practice Address - Fax:763-595-8414
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-05
Last Update Date:2016-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1706152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN2100002OtherMEDICA PRIMARY
MN23979OtherHEALTH PARTNERS
MN3C780MIOtherBLUE PLUS
MN2115998OtherMEDICA CHOICE
MN102877OtherUCARE
MN096744100Medicaid
MN19467WOOtherBCBS OF MN
MN2499537OtherMHP
MN096744100Medicaid