Provider Demographics
NPI:1114948734
Name:SIVERTSON, COURTNEY RAY (OD)
Entity Type:Individual
Prefix:DR
First Name:COURTNEY
Middle Name:RAY
Last Name:SIVERTSON
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 1:3632 10TH LN NW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55901-7032
Mailing Address - Country:US
Mailing Address - Phone:507-210-4894
Mailing Address - Fax:
Practice Address - Street 1:3632 10TH LN NW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55901-7032
Practice Address - Country:US
Practice Address - Phone:507-282-7121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6246453-9934152W00000X
MN3070152WC0802X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN09Y98SIOtherBLUE CROSS BLUE SHIELD
MN09Y99LIOtherBLUE CROSS BLUE SHIELD
MN39797WEOtherBLUE CROSS BLUE SHIELD
MN916891050630OtherPREFERRED ONE
MNHP77005OtherHEALTH PARTNERS
MN09Y96LIOtherBLUE CROSS BLUE SHIELD
MN411898525OtherHUMANA
MN6C464ANOtherBLUE CROSS BLUE SHIELD
MN138801OtherUCARE
MN628A8SIOtherBLUE CROSS BLUE SHIELD
MN763132000Medicaid
MN411898525OtherMAYO MANAGEMENT SERVICES
MN617A1SIOtherBLUE CROSS BLUE SHIELD
MNHP77005OtherHEALTH PARTNERS
MN628A8SIOtherBLUE CROSS BLUE SHIELD
MN411898525OtherMAYO MANAGEMENT SERVICES