1104880822 NPI number — VERONICA MESQUIDA M.D.

Table of content: VERONICA MESQUIDA M.D. (NPI 1104880822)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104880822 NPI number — VERONICA MESQUIDA M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MESQUIDA
Provider First Name:
VERONICA
Provider Middle Name:
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:
1104880822
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/27/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1000 E 1ST ST
Provider Second Line Business Mailing Address:
STE. 203
Provider Business Mailing Address City Name:
DULUTH
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55805-2297
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-249-6960
Provider Business Mailing Address Fax Number:
218-249-6969

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1000 E 1ST ST
Provider Second Line Business Practice Location Address:
STE. 203
Provider Business Practice Location Address City Name:
DULUTH
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55805-2297
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-249-6960
Provider Business Practice Location Address Fax Number:
218-249-6969
Provider Enumeration Date:
04/12/2006

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:  58120 , 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: CF2064 . This is a "RAILROAD GROUP" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 036118514 . This is a "ILLINIOS MD LICENSE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 200466110 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 036118514 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00252724 . This is a "RAIL ROAD MEDICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 753210 . This is a "MEDICARE GROUP" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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