Healthcare Provider Details

I. General information

NPI: 1164477709
Provider Name (Legal Business Name): MINNESOTA CENTER FOR OBESITY, METABOLISM & ENDOCRINOLOGY, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 02/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1185 TOWN CENTRE DR SUITE 220
EAGAN MN
55123-1187
US

IV. Provider business mailing address

1185 TOWN CENTRE DR SUITE 220
EAGAN MN
55123-1187
US

V. Phone/Fax

Practice location:
  • Phone: 651-379-1600
  • Fax: 651-379-1650
Mailing address:
  • Phone: 651-379-1600
  • Fax: 651-379-1650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1591
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number1591
License Number StateMN

VIII. Authorized Official

Name: REBECCA GONZALEZ-CAMPOY
Title or Position: COO
Credential:
Phone: 651-379-1600