Provider Demographics
NPI:1174596555
Name:CONSOER, JOHN MICHAEL (OD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:MICHAEL
Last Name:CONSOER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:MIKE
Other - Middle Name:
Other - Last Name:CONSOER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:8100 34TH AVE S
Mailing Address - Street 2:21110Q
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-1672
Mailing Address - Country:US
Mailing Address - Phone:952-883-5790
Mailing Address - Fax:952-883-5395
Practice Address - Street 1:8600 NICOLLET AVE S
Practice Address - Street 2:MAIL STOP 31500A
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55420-2824
Practice Address - Country:US
Practice Address - Phone:952-887-6600
Practice Address - Fax:952-886-7015
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1700152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T65418Medicare UPIN