Provider Demographics
NPI:1912286584
Name:SOUNDARA, AI (OD)
Entity type:Individual
Prefix:
First Name:AI
Middle Name:
Last Name:SOUNDARA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3745 LOUISIANA AVE S
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55426-4361
Mailing Address - Country:US
Mailing Address - Phone:952-926-1775
Mailing Address - Fax:952-926-3845
Practice Address - Street 1:3745 LOUISIANA AVE S
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55426-4361
Practice Address - Country:US
Practice Address - Phone:952-926-1775
Practice Address - Fax:952-926-3845
Is Sole Proprietor?:No
Enumeration Date:2011-08-12
Last Update Date:2011-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3253152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management