Healthcare Provider Details

I. General information

NPI: 1801836127
Provider Name (Legal Business Name): SANJIV KUMRA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 07/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2312 S 6TH ST SUITE F256/2B W
MINNEAPOLIS MN
55454-1336
US

IV. Provider business mailing address

2312 S 6TH ST SUITE F256/2B W
MINNEAPOLIS MN
55454-1336
US

V. Phone/Fax

Practice location:
  • Phone: 612-273-8700
  • Fax: 612-273-9779
Mailing address:
  • Phone: 612-273-8700
  • Fax: 612-273-9779

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number48480
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: