Provider Demographics
NPI:1336402668
Name:BROWN, GRACE A (OD)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:A
Last Name:BROWN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7767 ELM CREEK BLVD N
Mailing Address - Street 2:SUITE 140
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-7041
Mailing Address - Country:US
Mailing Address - Phone:763-416-6501
Mailing Address - Fax:763-416-6505
Practice Address - Street 1:7767 ELM CREEK BLVD N
Practice Address - Street 2:SUITE 140
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-7041
Practice Address - Country:US
Practice Address - Phone:763-416-6501
Practice Address - Fax:763-416-6505
Is Sole Proprietor?:No
Enumeration Date:2012-06-21
Last Update Date:2013-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3263-035152W00000X
MN3319152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI61320OtherDEAN HEALTH INSURANCE
WI61320OtherDEAN HEALTH INSURANCE