Provider Demographics
NPI:1811431810
Name:DVORAK CATARACT AND EYE LASER CLINIC, PA
Entity type:Organization
Organization Name:DVORAK CATARACT AND EYE LASER CLINIC, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:DVORAK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:320-774-3666
Mailing Address - Street 1:1311 2ND ST N STE 105
Mailing Address - Street 2:
Mailing Address - City:SAUK RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:56379-2582
Mailing Address - Country:US
Mailing Address - Phone:320-774-3666
Mailing Address - Fax:320-774-3660
Practice Address - Street 1:1311 2ND ST N STE 105
Practice Address - Street 2:
Practice Address - City:SAUK RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:56379-2582
Practice Address - Country:US
Practice Address - Phone:320-774-3666
Practice Address - Fax:320-774-3660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-09
Last Update Date:2016-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN39762207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNG64203Medicare UPIN