NPIMap

Organization Active NPI

South Suburban Eyecare Specialists PA

  • Optometrist
  • Lakeville, MN
National Provider Identifier
1407059678
Registry record updated Jun 2, 2011
On this page

Key facts

NPPES NPI Registry
Primary specialty
OptometristTaxonomy code 152W00000X
Legal business name
SOUTH SUBURBAN EYECARE SPECIALISTS PA
Practice address
17690 Kenwood TRL
Lakeville, MN 55044-9764
Phone
(952) 898-9588
Fax
(952) 898-2030
NPI assigned
Jun 6, 2007
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 2, 2011

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Andrew Joseph Mattson, ODNPI 1518037563
Title
President
Phone
(952) 898-9588

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
OptometristGroup: 193400000X SINGLE SPECIALTY GROUP 152W00000X Primary

Addresses

Primary practice location

17690 Kenwood TRL
Lakeville, MN 55044-9764

Mailing address

17690 Kenwood TRL
Lakeville, MN 55044-9764
Phone (952) 898-9588

Other identifiers 8

IdentifierTypeStateIssuer
176625200MedicaidMN
499R7LAOtherMNBLUE CROSS BLUE SHIELD MN
2203175OtherMNUNITED HEALTH CARE
79G34LAOtherMNBLUE PLUS
113428OtherMNHEALTH PARTNERS
2203175OtherMNMEDICA
2203175OtherMNSELECT CARE
A61971031584OtherMNPREFERRED ONE

Other names 1

  • Lakeville Family Eye Care PA Former legal business name

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 3

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1181088000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1306972800000",
    "number": "1407059678",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "17690 KENWOOD TRL",
            "city": "LAKEVILLE",
            "state": "MN",
            "postal_code": "550449764",
            "telephone_number": "952-898-9588",
            "fax_number": "952-898-2030"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "17690 KENWOOD TRL",
            "city": "LAKEVILLE",
            "state": "MN",
            "postal_code": "550449764",
            "telephone_number": "952-898-9588",
            "fax_number": "952-898-2030"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTH SUBURBAN EYECARE SPECIALISTS PA",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-06-06",
        "last_updated": "2011-06-02",
        "status": "A",
        "authorized_official_last_name": "MATTSON",
        "authorized_official_first_name": "ANDREW",
        "authorized_official_middle_name": "JOSEPH",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "952-898-9588",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "OD"
    },
    "taxonomies": [
        {
            "code": "152W00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Optometrist",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "176625200",
            "state": "MN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS BLUE SHIELD MN",
            "identifier": "499R7LA",
            "state": "MN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "UNITED HEALTH CARE",
            "identifier": "2203175",
            "state": "MN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE PLUS",
            "identifier": "79G34LA",
            "state": "MN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "HEALTH PARTNERS",
            "identifier": "113428",
            "state": "MN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICA",
            "identifier": "2203175",
            "state": "MN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "SELECT CARE",
            "identifier": "2203175",
            "state": "MN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PREFERRED ONE",
            "identifier": "A61971031584",
            "state": "MN"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Lakeville Family Eye Care PA",
            "code": "4",
            "type": "Former Legal Business Name"
        }
    ]
}

Other providers in Lakeville, MN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 2, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.