Provider Demographics
NPI:1437206679
Name:GUTFLEISCH, JOHN MAX (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MAX
Last Name:GUTFLEISCH
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 1:1111 2ND ST NE
Mailing Address - Street 2:PO BOX 464
Mailing Address - City:WASECA
Mailing Address - State:MN
Mailing Address - Zip Code:56093
Mailing Address - Country:US
Mailing Address - Phone:507-835-2020
Mailing Address - Fax:507-833-7677
Practice Address - Street 1:1111 2ND ST NE
Practice Address - Street 2:
Practice Address - City:WASECA
Practice Address - State:MN
Practice Address - Zip Code:56093
Practice Address - Country:US
Practice Address - Phone:507-835-2020
Practice Address - Fax:507-833-7677
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1592152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN988271009766OtherPREFERRED ONE
MN37095WAOtherBCBS OF MINNESOTA
MN114346OtherSOUTH COUNTRY HEALTH ALLI
MN423223200Medicaid
MN22-12339OtherMEDICA
MN83364OtherMAYO HEALTH PLAN
MNHP29935OtherHEALTH PARTNERS
MN419000250Medicare PIN
MN0291330001Medicare NSC
MN114346OtherSOUTH COUNTRY HEALTH ALLI
MN22-12339OtherMEDICA