Healthcare Provider Details

I. General information

NPI: 1285813451
Provider Name (Legal Business Name): JEROME D. POLAND, M.D., LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2007
Last Update Date: 07/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43500 MIGIZI DR
ONAMIA MN
56359-2241
US

IV. Provider business mailing address

1 3RD AVE NE
CROSBY MN
56441-1665
US

V. Phone/Fax

Practice location:
  • Phone: 320-532-4163
  • Fax: 320-532-4354
Mailing address:
  • Phone: 218-546-5108
  • Fax: 218-546-5736

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number2807770001
License Number StateMN

VIII. Authorized Official

Name: DR. JEROME D POLAND
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 218-546-5108