1932177060 NPI number — JACK DROGT MD

Table of content: JACK DROGT MD (NPI 1932177060)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932177060 NPI number — JACK DROGT MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DROGT
Provider First Name:
JACK
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1932177060
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/01/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
710 COMMERCE DR STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WOODBURY
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55125-4925
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-968-5042
Provider Business Mailing Address Fax Number:
651-968-5904

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2090 WOODWINDS DR
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
WOODBURY
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55125-2522
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-968-5801
Provider Business Practice Location Address Fax Number:
651-968-5899
Provider Enumeration Date:
03/14/2006

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: 207X00000X , with the licence number:  28922 , 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: 200023910 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 416873900 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com