Basic Information
| Provider Information | |||||||||
| NPI: | 1518975275 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CONSOER | ||||||||
| FirstName: | STEVEN | ||||||||
| MiddleName: | PETER | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1731 17TH AVE E | ||||||||
| Address2: | SHAKOPEE VISION CLINIC | ||||||||
| City: | SHAKOPEE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553793372 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9524455600 | ||||||||
| FaxNumber: | 9524455629 | ||||||||
| Practice Location | |||||||||
| Address1: | 1731 17TH AVE E | ||||||||
| Address2: | SHAKOPEE VISION CLINIC | ||||||||
| City: | SHAKOPEE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553793372 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9524455600 | ||||||||
| FaxNumber: | 9524455629 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2006 | ||||||||
| LastUpdateDate: | 01/30/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 1764 | MN | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | MC1104239 | 01 | DEA | OTHER | 2214561 | 01 | MN | MEDICA | OTHER | 315823300 | 05 | MN | MEDICAID | 0G498CO | 01 | MN | BCBS | OTHER |