Provider Demographics
NPI:1881610640
Name:BUFFALO EYE CLINIC P A
Entity type:Organization
Organization Name:BUFFALO EYE CLINIC P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT /OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RODNEY
Authorized Official - Middle Name:A
Authorized Official - Last Name:MELGARD
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:763-682-1282
Mailing Address - Street 1:103 CENTER DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BUFFALO
Mailing Address - State:MN
Mailing Address - Zip Code:55313-2957
Mailing Address - Country:US
Mailing Address - Phone:763-682-1282
Mailing Address - Fax:763-682-4205
Practice Address - Street 1:103 CENTER DR
Practice Address - Street 2:SUITE 100
Practice Address - City:BUFFALO
Practice Address - State:MN
Practice Address - Zip Code:55313-2957
Practice Address - Country:US
Practice Address - Phone:763-682-1282
Practice Address - Fax:763-682-4205
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2012-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN101068900Medicaid
MN0634280001Medicare NSC