Healthcare Provider Details

I. General information

NPI: 1528050119
Provider Name (Legal Business Name): EAGAN VALLEY PEDIATRICS, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14135 CEDAR AVE SUITE 100
APPLE VALLEY MN
55124-4522
US

IV. Provider business mailing address

14135 CEDAR AVE SUITE 100
APPLE VALLEY MN
55124-4522
US

V. Phone/Fax

Practice location:
  • Phone: 952-432-4373
  • Fax: 952-997-5679
Mailing address:
  • Phone: 952-432-4373
  • Fax: 952-997-5679

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JAMES E DUFORT
Title or Position: PRESIDENT
Credential: M.D.
Phone: 952-432-4373