Provider Demographics
NPI:1780696146
Name:OPTI-MIN PA
Entity type:Organization
Organization Name:OPTI-MIN PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITING
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:952-475-3787
Mailing Address - Street 1:7415 WAYZATA BLVD
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55426-1607
Mailing Address - Country:US
Mailing Address - Phone:952-475-3787
Mailing Address - Fax:
Practice Address - Street 1:7415 WAYZATA BLVD
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55426-1607
Practice Address - Country:US
Practice Address - Phone:952-475-3787
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-13
Last Update Date:2010-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN152W00000X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNC02774Medicare PIN