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General NPI Number Information
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NPI Number | 1114948734
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Entity Type | Individual
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Provider Name | COURTNEY RAY SIVERTSON O.D.
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Gender | Male
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Dates
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Enumeration Date | 07/21/2006
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Last Update Date | 07/19/2012
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Provider Practice Location Address
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Address Line | 3632 10TH LN NW
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City | ROCHESTER
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State | MN
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Zip | 55901-7032
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Country | US
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Telephone | 507-282-7121
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Fax |
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Provider Business Mailing Address
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Address Line | 3632 10TH LN NW
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City | ROCHESTER
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State | MN
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Zip | 55901-7032
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Country | US
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Telephone | 507-210-4894
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 6246453-9934
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License Number State | UT
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Taxonomy #2
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Taxonomy Code | 152WC0802X
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Taxonomy Name | Corneal and Contact Management Optometrist
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License Number | 3070
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License Number State | MN
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Taxonomy #3
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 3070
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License Number State | MN
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