Provider Demographics
NPI:1366520538
Name:DOFFIN, ANTHONY (OD)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:DOFFIN
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 1:3026 ASPEN LAKE DR NE
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55449-7517
Mailing Address - Country:US
Mailing Address - Phone:651-747-7311
Mailing Address - Fax:
Practice Address - Street 1:2929 PENTAGON DRIVE
Practice Address - Street 2:
Practice Address - City:SAINT ANTHONY
Practice Address - State:MN
Practice Address - Zip Code:55418
Practice Address - Country:US
Practice Address - Phone:612-781-4730
Practice Address - Fax:763-784-9627
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3004152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN171652200Medicaid
MN410002497Medicare ID - Type UnspecifiedOD MEDICARE
MN410002566Medicare ID - Type UnspecifiedOD MEDICARE
V04383Medicare UPIN
MNV04383Medicare UPIN
MN410002567Medicare ID - Type UnspecifiedOD MEDICARE
MN171652200``Medicaid