Healthcare Provider Details

I. General information

NPI: 1174055131
Provider Name (Legal Business Name): EFTU OMER BORU MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2017
Last Update Date: 10/09/2024
Certification Date: 10/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11269 JEFFERSON HWY N
CHAMPLIN MN
55316-3123
US

IV. Provider business mailing address

2925 CHICAGO AVE
MINNEAPOLIS MN
55407-1321
US

V. Phone/Fax

Practice location:
  • Phone: 763-236-0600
  • Fax: 763-427-0790
Mailing address:
  • Phone: 612-262-9000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number67712
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number71392
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: