Provider Demographics
NPI:1881634806
Name:LORENZ, BRYAN DAVID (OD)
Entity Type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:DAVID
Last Name:LORENZ
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 1:4161 2ND ST S
Mailing Address - Street 2:SHOPKO OPTICAL
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56301-3761
Mailing Address - Country:US
Mailing Address - Phone:320-253-5994
Mailing Address - Fax:320-253-5790
Practice Address - Street 1:4161 2ND ST S
Practice Address - Street 2:SHOPKO OPTICAL
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301-3761
Practice Address - Country:US
Practice Address - Phone:320-253-5994
Practice Address - Fax:320-253-5790
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2694152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U72780Medicare UPIN