Provider Demographics
NPI:1336133586
Name:ANDRIST, STANTON L (OD)
Entity Type:Individual
Prefix:
First Name:STANTON
Middle Name:L
Last Name:ANDRIST
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 1:420 CENTER AVE
Mailing Address - Street 2:SUITE 41
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56560-1957
Mailing Address - Country:US
Mailing Address - Phone:218-233-1624
Mailing Address - Fax:218-233-2058
Practice Address - Street 1:420 CENTER AVE
Practice Address - Street 2:SUITE 41
Practice Address - City:MOORHEAD
Practice Address - State:MN
Practice Address - Zip Code:56560-1957
Practice Address - Country:US
Practice Address - Phone:218-233-1624
Practice Address - Fax:218-233-2058
Is Sole Proprietor?:No
Enumeration Date:2005-09-02
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2021152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN947723300Medicaid
MNP01065711OtherRR MEDICARE
ND60344Medicaid
MN61000ANOtherBCBS PIN
U02796Medicare UPIN
ND60344Medicaid