Provider Demographics
NPI:1003922030
Name:BACKUS, ROY WILLIAM (OD)
Entity Type:Individual
Prefix:DR
First Name:ROY
Middle Name:WILLIAM
Last Name:BACKUS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38050 JEFFERY AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH BRANCH
Mailing Address - State:MN
Mailing Address - Zip Code:55056-5908
Mailing Address - Country:US
Mailing Address - Phone:651-237-0330
Mailing Address - Fax:
Practice Address - Street 1:200 12TH ST SW
Practice Address - Street 2:
Practice Address - City:FOREST LAKE
Practice Address - State:MN
Practice Address - Zip Code:55025-1482
Practice Address - Country:US
Practice Address - Phone:651-464-9767
Practice Address - Fax:651-464-9062
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2520152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN22-14902OtherMEDICA
MN48705OtherDAVIS VISION
MN4100006627Medicaid
MN6C258BAOtherBCBS
MN152144OtherCOLE VISION
MN410042867OtherRAILROAD PROVIDER #
MN212298OtherBCBS OPTI CHOICE #
MN12060OtherSPECTERA
MN489437500OtherMN HEALTH CARE PROVIDER #
MN71-0415188OtherSUPERIOR VISION
MN22-14902OtherMEDICA
MN6C258BAOtherBCBS