Provider Demographics
NPI:1861568727
Name:STAKSTON, MALIN CRAIG (OD)
Entity type:Individual
Prefix:
First Name:MALIN
Middle Name:CRAIG
Last Name:STAKSTON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12548 PARKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337
Mailing Address - Country:US
Mailing Address - Phone:952-895-8505
Mailing Address - Fax:952-890-7787
Practice Address - Street 1:12548 PARKWOOD DR
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337
Practice Address - Country:US
Practice Address - Phone:952-895-8505
Practice Address - Fax:952-890-7787
Is Sole Proprietor?:No
Enumeration Date:2006-11-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1535152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN33335OtherBCBS MPIN#
MN989810743001OtherPREFERRED ONE
MN16742STOtherPROVIDER #
MN33335OtherMPIN #
T39621Medicare UPIN