Healthcare Provider Details

I. General information

NPI: 1487864914
Provider Name (Legal Business Name): BEN HUME O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13195 WEAVER LAKE RD
MAPLE GROVE MN
55369-9410
US

IV. Provider business mailing address

13195 WEAVER LAKE RD
MAPLE GROVE MN
55369-9410
US

V. Phone/Fax

Practice location:
  • Phone: 763-420-5112
  • Fax:
Mailing address:
  • Phone: 763-420-5112
  • Fax: 763-420-6957

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2551
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3666
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: