Provider Demographics
NPI:1447328646
Name:JERALD L MONSON JR OD
Entity type:Organization
Organization Name:JERALD L MONSON JR OD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JERALD
Authorized Official - Middle Name:L
Authorized Official - Last Name:MONSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:507-835-4558
Mailing Address - Street 1:1270 STATE ST N
Mailing Address - Street 2:
Mailing Address - City:WASECA
Mailing Address - State:MN
Mailing Address - Zip Code:56093-2706
Mailing Address - Country:US
Mailing Address - Phone:507-835-4558
Mailing Address - Fax:507-835-4558
Practice Address - Street 1:1270 STATE ST N
Practice Address - Street 2:
Practice Address - City:WASECA
Practice Address - State:MN
Practice Address - Zip Code:56093-2706
Practice Address - Country:US
Practice Address - Phone:507-835-4558
Practice Address - Fax:507-835-4558
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2010-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN630070700Medicaid
MN114345OtherSCHA
MN37039MOOtherBCBS WASECA
MN630070700Medicaid
MN37039MOOtherBCBS WASECA