=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386716157
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OPHTHALMIC PLASTIC AND RECONSTRUCTIVE SURGERY, P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/15/2006
-----------------------------------------------------
Last Update Date | 04/27/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4887 E LAKE HARRIET BLVD
-----------------------------------------------------
City | MINNEAPOLIS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55419-5222
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-325-0317
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4887 E LAKE HARRIET BLVD
-----------------------------------------------------
City | MINNEAPOLIS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55419-5222
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-325-0317
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/OWNER
-----------------------------------------------------
Name | DR. RICHARD P CARROLL
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 612-325-0317
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 799
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------