Healthcare Provider Details

I. General information

NPI: 1003470568
Provider Name (Legal Business Name): NUTTAVUT SUMRANSUB M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2019
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 FULTON ST SE
MINNEAPOLIS MN
55455-4800
US

IV. Provider business mailing address

401 E RIVER PKWY STE 131
MINNEAPOLIS MN
55455-0368
US

V. Phone/Fax

Practice location:
  • Phone: 612-672-7422
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number81002
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: