Provider Demographics
NPI:1407967623
Name:ENGSTROM, JAMES WILLIAM (OD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:WILLIAM
Last Name:ENGSTROM
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 1:3238 43RD AVE S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-6635
Mailing Address - Country:US
Mailing Address - Phone:701-298-0730
Mailing Address - Fax:701-298-0730
Practice Address - Street 1:2101 ELM ST N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-2417
Practice Address - Country:US
Practice Address - Phone:701-239-3700
Practice Address - Fax:701-237-2683
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2013-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2579152W00000X
ND581152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN430628700Medicaid
MN410002299Medicare ID - Type Unspecified
MN430628700Medicaid