Healthcare Provider Details

I. General information

NPI: 1972784668
Provider Name (Legal Business Name): CALANDRA D THEISEN DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2007
Last Update Date: 11/21/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 39TH AVE NE SUITE 250
MINNEAPOLIS MN
55421-4379
US

IV. Provider business mailing address

2600 39TH AVE NE SUITE 250
MINNEAPOLIS MN
55421-4379
US

V. Phone/Fax

Practice location:
  • Phone: 612-788-7274
  • Fax: 612-788-3408
Mailing address:
  • Phone: 612-788-7274
  • Fax: 612-788-3408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number731
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: