Healthcare Provider Details

I. General information

NPI: 1932210150
Provider Name (Legal Business Name): JAMES W. ENGSTROM, O.D. AND ASSOCIATES, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1711 CENTER AVE W
DILWORTH MN
56529-1342
US

IV. Provider business mailing address

3238 43RD AVE S
FARGO ND
58104-6635
US

V. Phone/Fax

Practice location:
  • Phone: 218-233-8335
  • Fax: 218-233-3420
Mailing address:
  • Phone: 701-298-0730
  • Fax: 701-298-0730

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2579
License Number StateMN

VIII. Authorized Official

Name: JAMES WILLIAM ENGSTROM
Title or Position: OPTOMETRIST
Credential: O.D.
Phone: 218-233-8335