Taxonomy Codes
The NPI record includes the healthcare provider taxonomy classification, state license number and state of licensure. The following information regarding the scope of practice of this provider is available:
| No. |
Taxonomy Code |
Taxonomy Clasification |
Taxonomy Specialization |
License Number |
License State |
Primary |
| 1 | 152W00000X | Optometrist | | 2023 | MINNESOTA | No |
| 2 | 152W00000X | Optometrist | | 470 | NORTH DAKOTA | Yes |
Other Identifiers
The following information regarding additional identifiers associated to this NPI record includes the other identifier number, identifier type, identifier state and issuer.
| No. |
Other Provider Identifier |
Other Provider Identifier Type |
Other Provider Identifier State |
Other Provider Identifier Issuer |
| 1 | 308723900 | MEDICAID | MINNESOTA | |
| 2 | 59775BI | OTHER | | BLUE PLUS OF MN |
| 3 | 60081 | OTHER | | ND DEPT OF HUMAN |
| 4 | 60397 | OTHER | | VOCATIONAL REHAB CENTER |
| 5 | 140630 | OTHER | | U CARE MN |
| 6 | 2200440 | OTHER | | MEDICA |
| 7 | 59775BI | OTHER | MINNESOTA | BCBS MN |
| 8 | BIB800470 | OTHER | | VISION SERVICES INC |
| 9 | 410016499 | OTHER | | MEDICARE RAILROAD |
| 10 | 60397 | MEDICAID | MARYLAND | |
| 11 | BIB8881 | OTHER | | BLUE SHIELD OF ND VISION |
| 12 | 308723900 | OTHER | | MN DEPT OF HUMAN |
| 13 | 59775BI | OTHER | | MN COMPREHENSIVE CARE |
| 14 | BIB8881 | OTHER | NORTH DAKOTA | BCBS ND |
| 15 | BIB8881 | OTHER | | BLUE SHIELD OF ND ALTRU |
