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NPI Code Detail

MEDICARE: DONALD WAYNE KJOME M.D.

MEDICARE: DONALD WAYNE KJOME M.D.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207Q00000XFamily Medicine Physician22028MN

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1588749642
Entity Type Code : Individual
Provider Name (Legal Business Name) : DONALD WAYNE KJOME M.D.
Provider Business Mailing Address
First Line : 967 LAKE ST S
Second Line :
City : FOREST LAKE
State : MN
Zip : 55025-2616
Country : US
Telephone Number : 651-464-1113
Fax Number : 651-464-0853
Provider Business Practice Location Address
First Line : 967 LAKE ST S
Second Line :
City : FOREST LAKE
State : MN
Zip : 55025-2616
Country : US
Telephone Number : 651-464-1113
Fax Number : 651-464-0853
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/26/2006
Last Update Date : 03/17/2018

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