Provider Demographics
NPI:1235282633
Name:OAKDALE OPTICAL
Entity Type:Organization
Organization Name:OAKDALE OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:M
Authorized Official - Last Name:ELVERUM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:651-738-8040
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1460332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN56097ELOtherBCBS SITE
MN86629ELOtherBCBS PROVIDER
MN101869OtherUCARE
MN106141OtherUCARE HARDWARE
MN1C741OAOtherBCBS DISP
MN2222625OtherMEDICA
MN2113780OtherMEDICA DISP
MN106141OtherPREFERRED ONE GROUP
MN101869OtherUCARE