1275566929 NPI number — ELVIA G MORETA FREIRE M.D.

Table of content: ELVIA G MORETA FREIRE M.D. (NPI 1275566929)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275566929 NPI number — ELVIA G MORETA FREIRE M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MORETA FREIRE
Provider First Name:
ELVIA
Provider Middle Name:
G
Provider Name Prefix Text:
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:
1275566929
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/25/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2854 HIGHWAY 55 STE 130
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EAGAN
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55121-1776
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-224-4930
Provider Business Mailing Address Fax Number:
651-842-3391

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2854 HIGHWAY 55 STE 190
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EAGAN
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55121-1783
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-644-4277
Provider Business Practice Location Address Fax Number:
651-644-4018
Provider Enumeration Date:
07/08/2006

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: 207RR0500X , with the licence number:  40077 , 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: 570715300 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".