Healthcare Provider Details

I. General information

NPI: 1154887131
Provider Name (Legal Business Name): EYE PLASTIC SURGERY OF MINNESOTA PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2019
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

635 BIELENBERG DR STE 220
WOODBURY MN
55125-1413
US

IV. Provider business mailing address

635 BIELENBERG DR STE 220
WOODBURY MN
55125-1413
US

V. Phone/Fax

Practice location:
  • Phone: 651-998-9048
  • Fax:
Mailing address:
  • Phone: 651-998-9048
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207WX0200X
TaxonomyOphthalmic Plastic and Reconstructive Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MOHIT DEWAN
Title or Position: PRESIDENT
Credential: MD
Phone: 651-998-9048