Provider Demographics
NPI:1538646930
Name:FOURONE2020 PLLC
Entity Type:Organization
Organization Name:FOURONE2020 PLLC
Other - Org Name:DBA GREG B MARKESON OD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:GREG
Authorized Official - Middle Name:B
Authorized Official - Last Name:MARKESON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:612-812-4691
Mailing Address - Street 1:11146 SWEETWATER PATH
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55129-5293
Mailing Address - Country:US
Mailing Address - Phone:612-812-4691
Mailing Address - Fax:
Practice Address - Street 1:1750 ROBERT ST S
Practice Address - Street 2:
Practice Address - City:WEST ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55118-3919
Practice Address - Country:US
Practice Address - Phone:651-306-0412
Practice Address - Fax:651-306-0414
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-27
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2557152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1205917473OtherNPPES