Provider Demographics
NPI:1255397329
Name:BELLWARE, DAVID JOSEPH (OD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:JOSEPH
Last Name:BELLWARE
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 1:927 PEMBINA
Mailing Address - Street 2:
Mailing Address - City:DETROIT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56501
Mailing Address - Country:US
Mailing Address - Phone:218-375-3600
Mailing Address - Fax:
Practice Address - Street 1:40520 CO HWY 34
Practice Address - Street 2:WHITE EARTH HEALTH CENTER
Practice Address - City:OGEMA
Practice Address - State:MN
Practice Address - Zip Code:56569
Practice Address - Country:US
Practice Address - Phone:218-983-4300
Practice Address - Fax:218-983-6217
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2020-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4725152W00000X
OHT1529152W00000X
TN1777152W00000X
MN2759152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
2201833OtherMEDICA
39T60BEOtherBCBS
MN496820400Medicaid
585241029519OtherPREFERRED ONE
MN496820400Medicaid
8HZ92VMedicare ID - Type Unspecified