Provider Demographics
NPI:1720056641
Name:AUGDAHL, EDWARD (OD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:
Last Name:AUGDAHL
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 1:5515 XERXES AVE N
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN CENTER
Mailing Address - State:MN
Mailing Address - Zip Code:55430-2856
Mailing Address - Country:US
Mailing Address - Phone:763-560-1636
Mailing Address - Fax:763-560-4101
Practice Address - Street 1:PEARLE VISION
Practice Address - Street 2:5515 XERXES AVE NORTH
Practice Address - City:BROOKLYN CENTER
Practice Address - State:MN
Practice Address - Zip Code:55430
Practice Address - Country:US
Practice Address - Phone:763-560-1636
Practice Address - Fax:763-560-4101
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2009-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNMN2571152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
296N0AUOtherBCBS
MN2203101OtherMEDICA
MN781138100Medicaid
MNMN2571OtherEYEMED
MN24F55PEOtherBLUE CROSS/BLUE SHIELD
MN513T1PEOtherBLUE CROSS/BLUE SHIELD
MN1720056641OtherHEALTHPARTNERS
MN2260985OtherAMERICA'S PPO
1720056641Medicare PIN
MN2203101OtherMEDICA
MNU47566Medicare UPIN