Provider Demographics
NPI:1619077674
Name:PEARSON, JACK W (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:W
Last Name:PEARSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 S MILL ST
Mailing Address - Street 2:
Mailing Address - City:FERGUS FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56537-2756
Mailing Address - Country:US
Mailing Address - Phone:218-739-2221
Mailing Address - Fax:218-739-5501
Practice Address - Street 1:615 S MILL ST
Practice Address - Street 2:
Practice Address - City:FERGUS FALLS
Practice Address - State:MN
Practice Address - Zip Code:56537-2756
Practice Address - Country:US
Practice Address - Phone:218-739-2221
Practice Address - Fax:218-739-5501
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN20760207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN61515PEOtherBCBS
MN1008796OtherPREFERREDONE
ND13218Medicaid
NE41091744413Medicaid
MN08-01913OtherMEDICA
MN109530OtherUCAREMN
MNHP26722OtherHEALTHPARTNERS
NE41091744413Medicaid