Provider Demographics
NPI:1376537761
Name:MCCALL, JACQUELINE M (OD)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:M
Last Name:MCCALL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7870 EXCELSIOR RD
Mailing Address - Street 2:
Mailing Address - City:BAXTER
Mailing Address - State:MN
Mailing Address - Zip Code:56425-8427
Mailing Address - Country:US
Mailing Address - Phone:218-828-9545
Mailing Address - Fax:218-828-1572
Practice Address - Street 1:7870 EXCELSIOR RD
Practice Address - Street 2:
Practice Address - City:BAXTER
Practice Address - State:MN
Practice Address - Zip Code:56425-8427
Practice Address - Country:US
Practice Address - Phone:218-828-9545
Practice Address - Fax:218-828-1572
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-31
Last Update Date:2014-12-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN2091152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN198523000Medicaid
MN46B89MCOtherBCBS OF MN
MN198523000Medicaid
MN46B89MCOtherBCBS OF MN
MNU57678Medicare UPIN