Healthcare Provider Details

I. General information

NPI: 1114921996
Provider Name (Legal Business Name): OPHTHALMOLOGY PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2005
Last Update Date: 05/05/2025
Certification Date: 05/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 W 70TH ST
EDINA MN
55435-4227
US

IV. Provider business mailing address

3100 W 70TH ST
EDINA MN
55435-4227
US

V. Phone/Fax

Practice location:
  • Phone: 952-848-8300
  • Fax: 952-848-8313
Mailing address:
  • Phone: 952-848-8300
  • Fax: 952-848-8313

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number0026007
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number0026007
License Number StateMN

VIII. Authorized Official

Name: JESSICA LOUISE BERG
Title or Position: BUSINESS OFFICE
Credential:
Phone: 952-848-8383