Healthcare Provider Details

I. General information

NPI: 1053870147
Provider Name (Legal Business Name): DANIEL P MUNDT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/18/2019
Last Update Date: 04/03/2026
Certification Date: 04/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10150 NIAGARA LN N STE 100
MAPLE GROVE MN
55369-7588
US

IV. Provider business mailing address

2550 UNIVERSITY AVE W STE 110N
SAINT PAUL MN
55114-2001
US

V. Phone/Fax

Practice location:
  • Phone: 763-297-9700
  • Fax: 651-414-3101
Mailing address:
  • Phone: 763-297-9700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number78532
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: