Healthcare Provider Details

I. General information

NPI: 1063464329
Provider Name (Legal Business Name): JOHN T NORTHWOOD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 06/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14663 MERCANTILE DRIVE
HUGO MN
55038
US

IV. Provider business mailing address

5200 FAIRVIEW BLVD
WYOMING MN
55092-8013
US

V. Phone/Fax

Practice location:
  • Phone: 651-466-1900
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number38037
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: