1144333667 NPI number — JOHN WILLIAM CHEESEBRO D.P.M.

Table of content: JOHN WILLIAM CHEESEBRO D.P.M. (NPI 1144333667)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144333667 NPI number — JOHN WILLIAM CHEESEBRO D.P.M.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHEESEBRO
Provider First Name:
JOHN
Provider Middle Name:
WILLIAM
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.P.M.
Provider Gender Code:
M

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:
1144333667
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/22/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6625 LYNDALE AVE S STE 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RICHFIELD
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55423-2491
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-788-8778
Provider Business Mailing Address Fax Number:
612-869-3473

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2805 CAMPUS DR STE 225
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PLYMOUTH
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55441-2678
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-788-8778
Provider Business Practice Location Address Fax Number:
612-869-3473
Provider Enumeration Date:
08/17/2006

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: 213E00000X , with the licence number:  366 , 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: 0541840001 . This is a "ADMINISTAR DEFENSE ID" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 323225500 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 271055 . This is a "MEDICA PROVIDER ID" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: HP13053 . This is a "HEALTHPARTNERS PROVIDER #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 11691MI . This is a "BC/BS PROVIDER ID" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 411695192 . This is a "FEDERAL TAX ID" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com