Provider Demographics
NPI:1265483606
Name:LANDSVERK, DOUGLAS ROLAND (OD)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:ROLAND
Last Name:LANDSVERK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:312 MINNESOTA AVE N
Mailing Address - Street 2:
Mailing Address - City:AITKIN
Mailing Address - State:MN
Mailing Address - Zip Code:56431-1414
Mailing Address - Country:US
Mailing Address - Phone:218-927-3213
Mailing Address - Fax:218-927-2266
Practice Address - Street 1:312 MINNESOTA AVE N
Practice Address - Street 2:
Practice Address - City:AITKIN
Practice Address - State:MN
Practice Address - Zip Code:56431-1414
Practice Address - Country:US
Practice Address - Phone:218-927-3213
Practice Address - Fax:218-927-2266
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2009-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1998152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN2210683OtherMEDICA
MN5C924LAOtherBCBS
MN097723300Medicaid
MN097723300Medicaid
T65761Medicare UPIN