Provider Demographics
NPI:1427043660
Name:BLAKSTAD, ALYSON L (OD)
Entity Type:Individual
Prefix:
First Name:ALYSON
Middle Name:L
Last Name:BLAKSTAD
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 1:9801 DUPONT AVE S
Mailing Address - Street 2:SUITE 425
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55431-3100
Mailing Address - Country:US
Mailing Address - Phone:952-567-6092
Mailing Address - Fax:952-567-6176
Practice Address - Street 1:10709 WAYZATA BLVD STE 200
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-5509
Practice Address - Country:US
Practice Address - Phone:952-888-5800
Practice Address - Fax:952-567-6156
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2673152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN410045931OtherMEDICARE RAILROAD
MN293663100Medicaid
MN410045931OtherMEDICARE RAILROAD
MNU76398Medicare UPIN