Provider Demographics
NPI:1467517144
Name:CALVIN, DONALD WAYNE (OD)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:WAYNE
Last Name:CALVIN
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 1:2540 EAGLE VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55129-4206
Mailing Address - Country:US
Mailing Address - Phone:651-738-2758
Mailing Address - Fax:
Practice Address - Street 1:3001 WHITE BEAR AVE N
Practice Address - Street 2:SEARS BLDG
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-1215
Practice Address - Country:US
Practice Address - Phone:651-770-4274
Practice Address - Fax:651-770-1862
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1643152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN636023800Medicaid
MN636023800Medicaid
MNT40050Medicare UPIN