Provider Demographics
NPI:1730100181
Name:DR. GREGORY M. MACIK, OPTOMETRIST, P.A.
Entity Type:Organization
Organization Name:DR. GREGORY M. MACIK, OPTOMETRIST, P.A.
Other - Org Name:BURNSVILLE EYE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:M
Authorized Official - Last Name:MACIK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:952-894-1400
Mailing Address - Street 1:150 TRAVELER'S TRAIL EAST
Mailing Address - Street 2:SUITE D
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337
Mailing Address - Country:US
Mailing Address - Phone:952-894-1400
Mailing Address - Fax:952-808-2216
Practice Address - Street 1:150 TRAVELER'S TRAIL EAST
Practice Address - Street 2:SUITE D
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337
Practice Address - Country:US
Practice Address - Phone:952-894-1400
Practice Address - Fax:952-808-2216
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2973000152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN=========Medicare UPIN