Provider Demographics
NPI:1851397095
Name:MUELLERLEILE, JOHN M (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:M
Last Name:MUELLERLEILE
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:P.O. BOX 412
Mailing Address - Street 2:
Mailing Address - City:OWATONNA
Mailing Address - State:MN
Mailing Address - Zip Code:55060-0412
Mailing Address - Country:US
Mailing Address - Phone:507-451-5800
Mailing Address - Fax:507-451-4884
Practice Address - Street 1:121 W MAIN ST
Practice Address - Street 2:
Practice Address - City:OWATONNA
Practice Address - State:MN
Practice Address - Zip Code:55060-2970
Practice Address - Country:US
Practice Address - Phone:507-451-5800
Practice Address - Fax:507-451-4884
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-22
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLD1524000152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNT65896Medicare UPIN
MN0178930001Medicare NSC