Provider Demographics
NPI:1396816674
Name:SIPOLA, DON H (OD)
Entity Type:Individual
Prefix:
First Name:DON
Middle Name:H
Last Name:SIPOLA
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 1:413 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA
Mailing Address - State:MN
Mailing Address - Zip Code:55792-2525
Mailing Address - Country:US
Mailing Address - Phone:218-741-5886
Mailing Address - Fax:218-741-5894
Practice Address - Street 1:413 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:VIRGINIA
Practice Address - State:MN
Practice Address - Zip Code:55792-2525
Practice Address - Country:US
Practice Address - Phone:218-741-5886
Practice Address - Fax:218-741-5894
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-10
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1571152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN674023500Medicaid
MN0155120001Medicare NSC
MN419000861Medicare ID - Type Unspecified
MNT70854Medicare UPIN