Provider Demographics
NPI:1023168663
Name:NORTH DAKOTA EYE CLINIC, LTD
Entity type:Organization
Organization Name:NORTH DAKOTA EYE CLINIC, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:L
Authorized Official - Last Name:SCZEPANSKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:701-775-3151
Mailing Address - Street 1:3035 DEMERS AVE
Mailing Address - Street 2:NORTH DAKOTA EYE CLINIC, LTD
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-4040
Mailing Address - Country:US
Mailing Address - Phone:701-775-3151
Mailing Address - Fax:701-775-3153
Practice Address - Street 1:1820 S 42ND ST.
Practice Address - Street 2:NORTH DAKOTA EYE CLINIC, LTD
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-5820
Practice Address - Country:US
Practice Address - Phone:701-775-3151
Practice Address - Fax:701-775-3153
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND10080Medicaid
MN655224200Medicaid
0352000001Medicare NSC
MN0352000001Medicare NSC
MN655224200Medicaid