Provider Demographics
NPI:1205953437
Name:ST ANTHONY OPTOMETRIC CLINIC
Entity type:Organization
Organization Name:ST ANTHONY OPTOMETRIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:JEFFREY
Authorized Official - Last Name:HANSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:612-781-4730
Mailing Address - Street 1:2929 PENTAGON DR
Mailing Address - Street 2:
Mailing Address - City:ST ANTHONY
Mailing Address - State:MN
Mailing Address - Zip Code:55418-3208
Mailing Address - Country:US
Mailing Address - Phone:612-781-4730
Mailing Address - Fax:612-706-2337
Practice Address - Street 1:2929 PENTAGON DR
Practice Address - Street 2:
Practice Address - City:ST ANTHONY
Practice Address - State:MN
Practice Address - Zip Code:55418-3208
Practice Address - Country:US
Practice Address - Phone:612-781-4730
Practice Address - Fax:612-706-2337
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2443261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNU45093Medicare UPIN