Healthcare Provider Details

I. General information

NPI: 1356099352
Provider Name (Legal Business Name): MINNESOTA RETINA ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2022
Last Update Date: 10/23/2025
Certification Date: 10/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9801 DUPONT AVE S STE 110
BLOOMINGTON MN
55431-3179
US

IV. Provider business mailing address

8401 GOLDEN VALLEY RD STE 330
GOLDEN VALLEY MN
55427-4488
US

V. Phone/Fax

Practice location:
  • Phone: 612-355-6510
  • Fax:
Mailing address:
  • Phone: 763-416-7600
  • Fax: 763-416-7634

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number
License Number State

VIII. Authorized Official

Name: CLIFTON CHAD BAZHAW
Title or Position: SR VICE PRESIDENT REVENUE CYCLE
Credential:
Phone: 469-270-6658