Healthcare Provider Details

I. General information

NPI: 1962635193
Provider Name (Legal Business Name): FANG BU M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2009
Last Update Date: 10/06/2020
Certification Date: 10/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 CHICAGO AVE
MINNEAPOLIS MN
55404-4518
US

IV. Provider business mailing address

2525 CHICAGO AVE
MINNEAPOLIS MN
55404-4518
US

V. Phone/Fax

Practice location:
  • Phone: 612-813-6711
  • Fax: 612-813-7721
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0213X
TaxonomyPediatric Pathology Physician
License Number35.133826
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35.133826
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number34989
License Number StateSC
# 4
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2009013425
License Number StateMO
# 5
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberMD34989
License Number StateSC
# 6
Primary TaxonomyY
Taxonomy Code207ZP0213X
TaxonomyPediatric Pathology Physician
License Number67836
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: