Lynn Alan Sulerud, O.D. – Optometrist in Blaine, MN

Key facts

NPI: 1013060409
Entity type: Individual (NPI type 1)
Primary specialty: Optometrist 152W00000X
License: 1698 (MN)
Practice address: 12170 Aberdeen St NE
Blaine, MN 55449-4716
Phone: (763) 757-7000
Fax: (763) 757-3328
NPI assigned: Jan 19, 2007
Sex: Male
Sole proprietor: No

Medicare participation

Medicare fee-for-service enrollment: Not listed in the public Medicare enrollment file

National Provider Directory

Medicare enrollment (NPD): Yes

State licenses

License	State	Type	Specialty
1698	MN	MD	Optometrist

Specialties & licenses

Specialty (taxonomy)	Code	License	State	Primary
Optometrist	152W00000X	1698	MN	Yes

Addresses

Primary practice location

12170 Aberdeen St NE
Blaine, MN 55449-4716

Mailing address

12170 Aberdeen St NE
Blaine, MN 55449-4716
Phone (763) 757-7000

Other identifiers

Identifier	Type	State	Issuer
844523100	Medicaid	MN

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API JSON format, last updated by the provider on Sep 27, 2010.

{
    "created_epoch": "1169164800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1285545600000",
    "number": "1013060409",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "12170 ABERDEEN ST NE",
            "city": "BLAINE",
            "state": "MN",
            "postal_code": "554494716",
            "telephone_number": "763-757-7000",
            "fax_number": "763-757-3328"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "12170 ABERDEEN ST NE",
            "city": "BLAINE",
            "state": "MN",
            "postal_code": "554494716",
            "telephone_number": "763-757-7000",
            "fax_number": "763-757-3328"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "SULERUD",
        "first_name": "LYNN",
        "middle_name": "ALAN",
        "credential": "O.D.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2007-01-19",
        "last_updated": "2010-09-27",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "152W00000X",
            "taxonomy_group": "",
            "desc": "Optometrist",
            "state": "MN",
            "license": "1698",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "844523100",
            "state": "MN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Blaine, MN

All providers in Blaine, MN · Optometrist in Minnesota

Sources for this page

NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Sep 27, 2010. Information in NPPES is self-reported and not verified by CMS.
NUCC Health Care Provider Taxonomy: specialty names.
National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.