Provider Demographics
NPI:1366505323
Name:MINNESOTA VISION GROUP PA
Entity Type:Organization
Organization Name:MINNESOTA VISION GROUP PA
Other - Org Name:INSIGHT EYE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BURT
Authorized Official - Middle Name:W
Authorized Official - Last Name:DUBOW
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:320-253-0365
Mailing Address - Street 1:PO BOX 7654
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56302-7654
Mailing Address - Country:US
Mailing Address - Phone:320-253-0365
Mailing Address - Fax:320-253-9401
Practice Address - Street 1:206 W DIVISION ST
Practice Address - Street 2:
Practice Address - City:WAITE PARK
Practice Address - State:MN
Practice Address - Zip Code:56387-1331
Practice Address - Country:US
Practice Address - Phone:320-253-0365
Practice Address - Fax:320-253-9401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN161524600Medicaid
0464710001OtherNATIONAL SUPPLIER CLEARINGHOUSE
MN4C750MIOtherBLUE CROSS BLUE SHIELD
MN4C750MIOtherBLUE CROSS BLUE SHIELD