Healthcare Provider Details

I. General information

NPI: 1831321785
Provider Name (Legal Business Name): EVIDIO DOMINGO MUSIBAY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: EVIDIO DOMINGO MD

II. Dates (important events)

Enumeration Date: 08/11/2009
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 E 28TH ST STE 401
MINNEAPOLIS MN
55407-3723
US

IV. Provider business mailing address

2925 CHICAGO AVE
MINNEAPOLIS MN
55407-1321
US

V. Phone/Fax

Practice location:
  • Phone: 612-863-0200
  • Fax: 612-863-0235
Mailing address:
  • Phone: 612-262-9000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number52977
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code207RH0000X
TaxonomyHematology (Internal Medicine) Physician
License Number52977
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: