Provider Demographics
NPI:1760628788
Name:THIELKE, TRENT N (OD)
Entity Type:Individual
Prefix:
First Name:TRENT
Middle Name:N
Last Name:THIELKE
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 1:2080 WOODWINDS DR STE 110
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-2524
Mailing Address - Country:US
Mailing Address - Phone:651-738-6800
Mailing Address - Fax:
Practice Address - Street 1:2080 WOODWINDS DR STE 110
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-2524
Practice Address - Country:US
Practice Address - Phone:651-738-6800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-22
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3145-035152W00000X
MN3183152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist