Provider Demographics
NPI:1649235524
Name:SODERBERG, DENNIS RAYMOND (OD)
Entity Type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:RAYMOND
Last Name:SODERBERG
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 1:1620 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:BALDWIN
Mailing Address - State:WI
Mailing Address - Zip Code:54002-9033
Mailing Address - Country:US
Mailing Address - Phone:715-684-3310
Mailing Address - Fax:715-684-4560
Practice Address - Street 1:1620 10TH AVE
Practice Address - Street 2:
Practice Address - City:BALDWIN
Practice Address - State:WI
Practice Address - Zip Code:54002-9033
Practice Address - Country:US
Practice Address - Phone:715-684-3310
Practice Address - Fax:715-684-4560
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1396152W00000X
MN1549152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI391170106044OtherCLAIMS MANAGEMENT
WI391170106036OtherCOMPCARE
22-12358OtherMEDICA
WI38411800Medicaid
WI391170106028OtherBCBS
774002OtherPREFERRED ONE
795000OtherHEALTH PARTNERS
MN92530S0OtherBCBS
WI391170106044OtherCLAIMS MANAGEMENT
WI38411800Medicaid
22-12358OtherMEDICA