Healthcare Provider Details

I. General information

NPI: 1104146265
Provider Name (Legal Business Name): MINNESOTA EYE CONSULTANTS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2010
Last Update Date: 02/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11091 ULYSSES ST NE SUITE 300
BLAINE MN
55434-4237
US

IV. Provider business mailing address

9801 DUPONT AVE S SUITE 425
BLOOMINGTON MN
55431-3100
US

V. Phone/Fax

Practice location:
  • Phone: 952-888-5800
  • Fax: 763-421-8297
Mailing address:
  • Phone: 952-888-5800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number31920
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: BRENT L WILDE
Title or Position: PRESIDENT
Credential:
Phone: 952-567-6143