1558350207 NPI number — GINA MARIE DOEDEN OD

Table of content: GINA MARIE DOEDEN OD (NPI 1558350207)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558350207 NPI number — GINA MARIE DOEDEN OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DOEDEN
Provider First Name:
GINA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1558350207
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/04/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9801 DUPONT S AVE 425
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BLOOMINGTON
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55431-3873
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-888-5800
Provider Business Mailing Address Fax Number:
952-567-6156

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9801 DUPONT AVE S
Provider Second Line Business Practice Location Address:
200
Provider Business Practice Location Address City Name:
BLOOMINGTON
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55431-3100
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-888-5800
Provider Business Practice Location Address Fax Number:
952-567-6156
Provider Enumeration Date:
10/17/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  2854 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152WC0802X , with the licence number: 2854 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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