Provider Demographics
NPI:1982769501
Name:CALVIN OPTOMETRY PLLC
Entity type:Organization
Organization Name:CALVIN OPTOMETRY PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:CALVIN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:651-739-5173
Mailing Address - Street 1:2540 EAGLE VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55129-4206
Mailing Address - Country:US
Mailing Address - Phone:651-738-2758
Mailing Address - Fax:
Practice Address - Street 1:1995 BURNS AVE.
Practice Address - Street 2:SUITE B
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55119-4906
Practice Address - Country:US
Practice Address - Phone:651-739-5173
Practice Address - Fax:651-739-8907
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-26
Last Update Date:2009-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1643152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN669493400Medicaid
MNT40050Medicare UPIN
MN410002032Medicare ID - Type Unspecified
MN669493400Medicaid