MEDICARE: DAVID MICHAEL PERRY O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	1932	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0642002	OTHER	MN	PREFERRED ONE
2	2214899	OTHER	MN	MEDICA
3	HP21875	OTHER	MN	HEALTH PARTNERS
4	105475	OTHER	MN	UCARE
5	27024PE	OTHER	MN	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1740230580
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAVID MICHAEL PERRY O.D.

Provider Business Mailing Address
First Line	:	4750 WASHINGTON SQ
Second Line	:
City	:	WHITE BEAR LAKE
State	:	MN
Zip	:	55110-3257
Country	:	US
Telephone Number	:	651-429-3379
Fax Number	:	651-429-8681

Provider Business Practice Location Address
First Line	:	4750 WASHINGTON SQ
Second Line	:
City	:	WHITE BEAR LAKE
State	:	MN
Zip	:	55110-3257
Country	:	US
Telephone Number	:	651-429-3379
Fax Number	:	651-429-8681

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/11/2006
Last Update Date	:	07/08/2007

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