Individual
DR. BRIAN DWIGHT GRUDEM
Active
Sole proprietor
Provider details
NPI number
Gender
Man
Credential
O.D.
Contact information
Practice address
4720 WHITE BEAR PKWY, WHITE BEAR LAKE, MN 55110-3336
(651) 426-2747
(651) 426-9838
Mailing address
4720 WHITE BEAR PKWY, WHITE BEAR LAKE, MN 55110-3336
(651) 426-2747
(651) 426-9838
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
LD1732000
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0N456GR
BLUE CROSS BLUE SHIELD
MN
01
—
22-02690
MEDICA
MN
01
—
22-02779
MEDICA
MN
01
—
965400656001
PREFERRED ONE
MN
01
—
HP29577
HEALTH PARTNERS
MN
01
—
P00124841
MEDICARE RAILROAD RETIREM
MN
Enumeration date
08/16/2005
Last updated
07/08/2007
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