Unknown Individual – Optometrist, NPI 1629055314

Unknown Individual is a healthcare provider. based in Shakopee, Minnesota. specializing in Optometrist. They hold a License No. 1713 (WI). The NPI Number for Unknown Individual is 1629055314

Main info

Organization
Inactive
46 Years Of Experience
Accepts Medicare Assignment
Name
Unknown Individual
NPI
1629055314
Phone
(952) 993-7750
Address
1415 SAINT FRANCIS AVE
Deactivation Date
30 January 2022

Doctor Profile

Medical School Name
SOUTHERN CALIFORNIA COLLEGE OF OPTOMETRY
Secondary Phone
9529934300
Graduation Year
1980 (46 years ago)
PAC ID
2961538699
Group Practice PAC ID
7911819438
Professional Enrollment ID
I20100331001186
Data current as of
19 May 2026

Profile Insights

NPPES metrics only — not quality of care.

Methodology
Experience23
Completeness75
Years active:0State licenses:2Digital endpointsOther names

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Provider Addresses for Unknown Individual

  • 1415, Saint Francis Avenue, Shakopee, Scott County, Minnesota, 55379, United States

    SHAKOPEE, MN 553793374

    Phone: (952) 993-7750

    Type: Location

  • 33rd Avenue South, Wenonah, Minneapolis, Hennepin County, Minnesota, 55417, United States

    PO BOX 1309 MAIL STOP 21110Q

    MINNEAPOLIS, MN 554254516

    Phone: (952) 993-7750

    Type: Mailing

NPPES updates history

No NPPES updates recorded for this provider.

Prescription Activity

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Open Payments (CMS)

No Open Payments data available for this provider.

This can happen when there are no reportable CMS Open Payments records.

Medicare Enrollment & Revalidation

Source: CMS public data · Not endorsed by CMS ·

Educational use only—not medical, billing, or legal advice.

No Medicare enrollment or revalidation data available for this provider in our database.

Prepare CMS-855 application → · Look up this NPI in PECOS → · Verify on CMS PECOS

Medicare Utilization (FFS)

Source: CMS public data · Not endorsed by CMS · Beneficiary counts under 11 are suppressed in source data ·

Educational use only—not medical, billing, or legal advice.

No Medicare fee-for-service utilization data available for this provider in our database.

Insurance plans in this area (ZIP 55379)

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Group practice members

Group practice members are other physicians who share the same Group Practice PAC ID with this doctor. When doctors form a group practice and register in PECOS as a single entity, they receive a shared identification number. This table lists all providers in the same group practice.
PAC ID: 7911819438View full group profile
NameSpecialtyState
O B S T E T R I C S/ G Y N E C O L O G YMN
Family PracticeMN
-MN
Pulmonary Disease, Critical Care (Intensivists), Internal MedicineMN
Cardiac ElectrophysiologyMN
Family PracticeMN
Physician AssistantMN
Physical Therapist In Private PracticeMN
Physician AssistantMN
D E R M A T O L O G YMN

Reviews

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Frequently asked questions

How is Unknown Individual identified in CMS data?
CMS-hosted NPPES data lists Unknown Individual with NPI 1629055314.
Is Unknown Individual's NPI deactivated?
The extract indicates Unknown Individual is not in an active NPI state.
What is Unknown Individual's primary classification?
Optometrist is the headline specialty for Unknown Individual here. Clinical services aligned with this taxonomy classification.
Does Unknown Individual list a practice location?
Patients near Shakopee, Minnesota may find Unknown Individual in results; validate coverage separately.
Is the information about Unknown Individual up to date?
Data updates when providers file changes in NPPES — treat critical facts as "verify if unsure."

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