Facts
- Status
- A
- Credential
- MD
- Type
- Individual
- Enumeration date
- 2014-06-20
- Last updated
- 2024-07-10
Licenses
- License NE
- 7227
- License MN
- 62307
- License WI
- 67342-20
Location
- Practice location
- 1027 WASHINGTON AVE
- City
- DETROIT LAKES MN
- Postal code
- 565013409
- Phone
- 218-847-5611
Medicare
- PECOS
- A PECOS enrollment row matches this NPI.
LEIE
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Nearby
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Removal request
Public data from NPPES and CMS. Not a credentialing determination.