Healthcare Provider Details

I. General information

NPI: 1124016597
Provider Name (Legal Business Name): TODD LAVERNE KANZENBACH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2005
Last Update Date: 01/20/2022
Certification Date: 01/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 CARKOSKI COMMONS MINNESOTA STATE UNIVERSITY, MANKATO
MANKATO MN
56001-6030
US

IV. Provider business mailing address

600 MAYWOOD AVE 21 CARKOSKI COMMONS
MANKATO MN
56001-6441
US

V. Phone/Fax

Practice location:
  • Phone: 507-389-6276
  • Fax: 507-389-5787
Mailing address:
  • Phone: 507-389-1430
  • Fax: 507-389-5787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number38627
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: