Provider Demographics
NPI:1932210150
Name:JAMES W. ENGSTROM, O.D. AND ASSOCIATES, PLLC
Entity Type:Organization
Organization Name:JAMES W. ENGSTROM, O.D. AND ASSOCIATES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:ENGSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:218-233-8335
Mailing Address - Street 1:3238 43RD AVE S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-6635
Mailing Address - Country:US
Mailing Address - Phone:701-298-0730
Mailing Address - Fax:701-298-0730
Practice Address - Street 1:1711 CENTER AVE W
Practice Address - Street 2:
Practice Address - City:DILWORTH
Practice Address - State:MN
Practice Address - Zip Code:56529-1342
Practice Address - Country:US
Practice Address - Phone:218-233-8335
Practice Address - Fax:218-233-3420
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2579152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NDU77455Medicare UPIN
MNC03725Medicare ID - Type Unspecified