Provider Demographics
NPI:1083645626
Name:DAMLO, PAUL M (OD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:M
Last Name:DAMLO
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 1:2070-72 BURNSVILLE CENTER
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55306-4438
Mailing Address - Country:US
Mailing Address - Phone:952-435-3686
Mailing Address - Fax:952-435-3074
Practice Address - Street 1:2070-72 BURNSVILLE CENTER
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55306-4438
Practice Address - Country:US
Practice Address - Phone:952-435-3686
Practice Address - Fax:952-435-3074
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2476152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNU52956Medicare UPIN