Provider Demographics
NPI:1255431961
Name:TRAVERSE, ANTHONY CHARLES (OD)
Entity type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:CHARLES
Last Name:TRAVERSE
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 1:10600 OLD COUNTY ROAD 15
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55441-6210
Mailing Address - Country:US
Mailing Address - Phone:763-545-8850
Mailing Address - Fax:763-544-1257
Practice Address - Street 1:10600 OLD COUNTY ROAD 15
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55441-6210
Practice Address - Country:US
Practice Address - Phone:763-545-8850
Practice Address - Fax:763-544-1257
Is Sole Proprietor?:No
Enumeration Date:2006-09-23
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLD2933000152W00000X, 152WC0802X, 152WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN2202143OtherMEDICA
MN050972800Medicaid
MN417R7TROtherBLUE CROSS BLUE SHIELD
MN977521040529OtherPERFERRED ONE
MN2202143OtherMEDICA
MNU96568Medicare UPIN