Healthcare Provider Details

I. General information

NPI: 1790868925
Provider Name (Legal Business Name): SHAHNAZ SULTAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 10/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 FULTON ST SE
MINNEAPOLIS MN
55455-4800
US

IV. Provider business mailing address

720 WASHINGTON AVE SE STE 200
MINNEAPOLIS MN
55414-2924
US

V. Phone/Fax

Practice location:
  • Phone: 612-672-7422
  • Fax: 352-392-3618
Mailing address:
  • Phone: 612-884-0331
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberME98007
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number200200812
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number66414
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: