Provider Demographics
NPI:1083601165
Name:SUFKA, MICHAEL DAVID (OD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DAVID
Last Name:SUFKA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:MICHAEL
Other - Middle Name:D
Other - Last Name:SUFKA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OK
Mailing Address - Street 1:1545 NORTHWAY DR
Mailing Address - Street 2:STE 120
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-1940
Mailing Address - Country:US
Mailing Address - Phone:320-253-2441
Mailing Address - Fax:320-253-2446
Practice Address - Street 1:1545 NORTHWAY DR
Practice Address - Street 2:STE 120
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-1940
Practice Address - Country:US
Practice Address - Phone:320-253-2441
Practice Address - Fax:320-253-2446
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2751152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN76939Medicare UPIN