Provider Demographics
NPI:1063499762
Name:PASTRYK, SCOTT M (OD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:M
Last Name:PASTRYK
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 1:855 MANKATO AVE
Mailing Address - Street 2:
Mailing Address - City:WINONA
Mailing Address - State:MN
Mailing Address - Zip Code:55987-4868
Mailing Address - Country:US
Mailing Address - Phone:507-454-3650
Mailing Address - Fax:
Practice Address - Street 1:855 MANKATO AVE
Practice Address - Street 2:
Practice Address - City:WINONA
Practice Address - State:MN
Practice Address - Zip Code:55987-4868
Practice Address - Country:US
Practice Address - Phone:507-454-3650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-23
Last Update Date:2011-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003284A152W00000X
MN3115152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN18003284AOtherOPTOMETRIST LICENSE
IN200498370Medicaid
IN18003284AOtherOPTOMETRIST LICENSE
IN200498370Medicaid