1205846896 NPI number — DR. EVELYN JUDITH TORRES-DEDEKER M.D.

Table of content: DR. EVELYN JUDITH TORRES-DEDEKER M.D. (NPI 1205846896)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205846896 NPI number — DR. EVELYN JUDITH TORRES-DEDEKER M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TORRES-DEDEKER
Provider First Name:
EVELYN
Provider Middle Name:
JUDITH
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1205846896
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/21/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3625 W 65TH ST
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
EDINA
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55435-2106
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-920-7001
Provider Business Mailing Address Fax Number:
952-920-2245

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3625 W 65TH ST
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
EDINA
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55435-2106
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-920-7001
Provider Business Practice Location Address Fax Number:
952-920-2245
Provider Enumeration Date:
08/08/2006

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: 207V00000X , with the licence number:  33170 , 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)

  • Identifier: 226308400 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00908TO . This is a "BCBS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 0722496 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".