Provider Demographics
NPI:1053463554
Name:ELVERUM, JOHN M (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:M
Last Name:ELVERUM
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 1:7013 10TH ST N
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55128-5938
Mailing Address - Country:US
Mailing Address - Phone:651-738-8040
Mailing Address - Fax:651-714-0759
Practice Address - Street 1:7013 10TH ST N
Practice Address - Street 2:
Practice Address - City:OAKDALE
Practice Address - State:MN
Practice Address - Zip Code:55128-5938
Practice Address - Country:US
Practice Address - Phone:651-738-8040
Practice Address - Fax:651-714-0759
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1460152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN101869OtherUCARE
MN2222625OtherMEDICA
MN47785OtherPREFERRED ONE
MN47785OtherPREFERRED ONE