Healthcare Provider Details

I. General information

NPI: 1437103629
Provider Name (Legal Business Name): IRFAN MOHAMMAD ALTAFULLAH M.B., B.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 05/17/2022
Certification Date: 05/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4225 GOLDEN VALLEY RD
GOLDEN VALLEY MN
55422-4215
US

IV. Provider business mailing address

4225 GOLDEN VALLEY RD
GOLDEN VALLEY MN
55422-4215
US

V. Phone/Fax

Practice location:
  • Phone: 763-588-0661
  • Fax: 763-287-2310
Mailing address:
  • Phone: 763-588-0661
  • Fax: 763-287-2310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number31625
License Number StateMN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1437103629
Identifier TypeMEDICAID
Identifier StateMN
Identifier Issuer
# 2
Identifier100277C029
Identifier TypeOTHER
Identifier StateMN
Identifier IssuerUCARE
# 3
Identifier0265046
Identifier TypeOTHER
Identifier StateMN
Identifier IssuerPREFERRED ONE
# 4
Identifier0522654
Identifier TypeOTHER
Identifier StateMN
Identifier IssuerMEDICA
# 5
Identifier1D717AL
Identifier TypeOTHER
Identifier StateMN
Identifier IssuerBCBS OF MN
# 6
Identifier31739300
Identifier TypeMEDICAID
Identifier StateWI
Identifier Issuer
# 7
Identifier130006223
Identifier TypeOTHER
Identifier StateMN
Identifier IssuerRAILROAD MEDICARE
# 8
IdentifierHP12787
Identifier TypeOTHER
Identifier StateMN
Identifier IssuerHEALTHPARTNERS
# 9
Identifier22781
Identifier TypeOTHER
Identifier StateMN
Identifier IssuerAMERICA'S PPO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: