Provider Demographics
NPI:1477512697
Name:BOHJANEN, ERIC JACK-MUN (OD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:JACK-MUN
Last Name:BOHJANEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:ERIC
Other - Middle Name:J
Other - Last Name:BOHJANEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:2106 LONDON RD
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55812-2127
Mailing Address - Country:US
Mailing Address - Phone:218-522-4645
Mailing Address - Fax:218-481-7811
Practice Address - Street 1:2106 LONDON RD
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55812-2127
Practice Address - Country:US
Practice Address - Phone:218-522-4645
Practice Address - Fax:218-481-7811
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3420156FX1800X, 332H00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
No332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1477512697Medicaid
MNH400321094OtherINDIVIDUAL PTAN