Provider Demographics
NPI:1407844822
Name:DUBOW, BURT
Entity Type:Individual
Prefix:
First Name:BURT
Middle Name:
Last Name:DUBOW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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 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
Is Sole Proprietor?:No
Enumeration Date:2005-10-10
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1604152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN14144OtherMAYO MTG
MN73001OtherPREFERRED ONE
MN2220109OtherMEDICA
MNT65469OtherSELECT CARE
MN54290DUOtherBLUE CROSS BLUE SHIELD
MN54290DUOtherBLUE CROSS BLUE SHIELD
MN0464710001Medicare PIN