MEDICARE: ROBERT DODGE O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	2510	MN

General Provider Information

NPI Number	:	1164424370
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROBERT DODGE O.D.

Provider Business Mailing Address
First Line	:	PO BOX 48451
Second Line	:
City	:	COON RAPIDS
State	:	MN
Zip	:	55448-0451
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	12737 RIVERDALE BLVD NW
Second Line	:
City	:	COON RAPIDS
State	:	MN
Zip	:	55448-1253
Country	:	US
Telephone Number	:	763-433-3468
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/01/2005
Last Update Date	:	07/09/2007

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