Healthcare Provider Details

I. General information

NPI: 1346650025
Provider Name (Legal Business Name): MICHAEL DAVID JOSE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2014
Last Update Date: 08/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 NORTHWOODS DR
ARDEN HILLS MN
55112
US

IV. Provider business mailing address

2450 RIVERSIDE AVE
MINNEAPOLIS MN
55454-1450
US

V. Phone/Fax

Practice location:
  • Phone: 651-787-9600
  • Fax:
Mailing address:
  • Phone: 612-273-9824
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number60470
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: