Provider Demographics
NPI:1417954553
Name:DALEN, DARWIN (OD)
Entity Type:Individual
Prefix:DR
First Name:DARWIN
Middle Name:
Last Name:DALEN
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 1:201 NW 4TH ST
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744-2753
Mailing Address - Country:US
Mailing Address - Phone:218-326-9619
Mailing Address - Fax:218-326-9619
Practice Address - Street 1:201 NW 4TH ST
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-2753
Practice Address - Country:US
Practice Address - Phone:218-326-9619
Practice Address - Fax:218-326-9619
Is Sole Proprietor?:No
Enumeration Date:2005-07-05
Last Update Date:2008-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2529152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN5C957DAOtherBLUE CROSS BLUE SHIELD
MN1190310001Medicare NSC
MN5C957DAOtherBLUE CROSS BLUE SHIELD