Provider Demographics
NPI:1902880461
Name:OPHTHALMOLOGY ASSOCIATES
Entity Type:Organization
Organization Name:OPHTHALMOLOGY ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR
Authorized Official - Prefix:DR
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:WALTER
Authorized Official - Last Name:JACOBSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:952-927-7138
Mailing Address - Street 1:6533 DREW AVE S
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435
Mailing Address - Country:US
Mailing Address - Phone:952-927-7138
Mailing Address - Fax:952-924-4021
Practice Address - Street 1:6533 DREW AVE S
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435
Practice Address - Country:US
Practice Address - Phone:952-927-7138
Practice Address - Fax:952-924-4021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-30
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNC03573Medicare ID - Type Unspecified