Provider Demographics
NPI:1689777179
Name:PRESTON, PAUL (OD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:
Last Name:PRESTON
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 1:385 W MARKET
Mailing Address - Street 2:MALL OF AMERICA
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-5523
Mailing Address - Country:US
Mailing Address - Phone:952-854-4500
Mailing Address - Fax:952-858-8525
Practice Address - Street 1:385 W MARKET
Practice Address - Street 2:MALL OF AMERICA
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55425-5523
Practice Address - Country:US
Practice Address - Phone:952-854-4500
Practice Address - Fax:952-858-8525
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2010-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNMN2559152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN299K8PROtherMOA
MNMN2559OtherEYEMED
MN183M3PROtherBCBS/MN ST LOUIS PK
MN2200266OtherMEDICA/UNITED HEALTH CARE
MN2219201OtherAMERICA'S PPO
MN2202539OtherMEDICA/UNITED HEALTH CARE
MN370517000Medicaid
MN370517000Medicaid
MN410003196Medicare PIN
MN2200266OtherMEDICA/UNITED HEALTH CARE
MN410002228Medicare ID - Type UnspecifiedMALL OF AMERICA