Provider Demographics
NPI:1528116969
Name:DR. ROBERT NYRE
Entity type:Organization
Organization Name:DR. ROBERT NYRE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:PETER
Authorized Official - Last Name:NYRE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:701-852-2020
Mailing Address - Street 1:1100 N BROADWAY STE 110
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58703-1328
Mailing Address - Country:US
Mailing Address - Phone:701-852-2020
Mailing Address - Fax:701-852-7853
Practice Address - Street 1:1100 N BROADWAY STE 110
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58703-1328
Practice Address - Country:US
Practice Address - Phone:701-852-2020
Practice Address - Fax:701-852-7853
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND405152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND60386Medicaid
ND60636Medicaid
NDT66919Medicare UPIN
ND0272570001Medicare NSC
ND70647Medicare PIN
ND60386Medicaid
ND13035Medicare PIN