Provider Demographics
NPI:1770507170
Name:BAUMGARTNER, TODD GORDON (OD)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:GORDON
Last Name:BAUMGARTNER
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 1:313 1ST ST SE
Mailing Address - Street 2:
Mailing Address - City:LITTLE FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56345-3005
Mailing Address - Country:US
Mailing Address - Phone:320-632-3673
Mailing Address - Fax:320-632-3677
Practice Address - Street 1:313 1ST ST SE
Practice Address - Street 2:
Practice Address - City:LITTLE FALLS
Practice Address - State:MN
Practice Address - Zip Code:56345-3005
Practice Address - Country:US
Practice Address - Phone:320-632-3673
Practice Address - Fax:320-632-3677
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2014-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2114152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN058823700Medicaid
MN01006332OtherPREFERRED ONE
MN121964E979OtherUCARE
MN22-14261OtherMEDICA
MN410029610OtherRAILROAD MEDICARE
FM4C930BAOtherBLUE CROSS BLUE SHIELD
MNHP26999OtherHEALTH PARTNERS
MN410000701Medicare ID - Type Unspecified
MN058823700Medicaid