Provider Demographics
NPI:1649222902
Name:EMERSON, MICHAEL VAUGHN (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:VAUGHN
Last Name:EMERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:710 E 24TH ST
Mailing Address - Street 2:SUITE 304
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404-3846
Mailing Address - Country:US
Mailing Address - Phone:612-871-2292
Mailing Address - Fax:952-460-5274
Practice Address - Street 1:710 E 24TH ST STE 304
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-3846
Practice Address - Country:US
Practice Address - Phone:612-871-2292
Practice Address - Fax:952-460-5274
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN50633207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR213372Medicaid
I33300Medicare UPIN
MN180001360Medicare PIN