Provider Demographics
NPI:1013060409
Name:SULERUD, LYNN ALAN (OD)
Entity type:Individual
Prefix:
First Name:LYNN
Middle Name:ALAN
Last Name:SULERUD
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 1:12170 ABERDEEN ST NE
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55449-4716
Mailing Address - Country:US
Mailing Address - Phone:763-757-7000
Mailing Address - Fax:763-757-3328
Practice Address - Street 1:12170 ABERDEEN ST NE
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55449-4716
Practice Address - Country:US
Practice Address - Phone:763-757-7000
Practice Address - Fax:763-757-3328
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2010-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1698152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN844523100Medicaid
MN1043363401Medicare NSC
MNT66186Medicare UPIN
MN844523100Medicaid