Provider Demographics
NPI:1992828602
Name:SOLBRACK, DANIEL WILLIAM (OD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:WILLIAM
Last Name:SOLBRACK
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 1:32079 JACKSON CT NE
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MN
Mailing Address - Zip Code:55008-6878
Mailing Address - Country:US
Mailing Address - Phone:763-689-5853
Mailing Address - Fax:
Practice Address - Street 1:523 1ST ST
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:MN
Practice Address - Zip Code:55371-1603
Practice Address - Country:US
Practice Address - Phone:763-389-3150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2273152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN001029400Medicaid
MN419000531Medicare ID - Type Unspecified
MN001029400Medicaid