Provider Demographics
NPI:1861534315
Name:LOVDOKKEN, VERNON BRUCE (OD)
Entity type:Individual
Prefix:DR
First Name:VERNON
Middle Name:BRUCE
Last Name:LOVDOKKEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:11501 JEFFERSON ST NORTH EAST
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55434
Mailing Address - Country:US
Mailing Address - Phone:612-867-1431
Mailing Address - Fax:
Practice Address - Street 1:12700 LAKE BOULEVARD
Practice Address - Street 2:
Practice Address - City:LINDSTROM
Practice Address - State:MN
Practice Address - Zip Code:55045
Practice Address - Country:US
Practice Address - Phone:651-257-2419
Practice Address - Fax:651-257-2419
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2142152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN628823500Medicaid
MN628823500Medicaid
MN419000623Medicare ID - Type Unspecified