Healthcare Provider Details

I. General information

NPI: 1366961542
Provider Name (Legal Business Name): DOREEN LUBI ISUBIKALU
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2017
Last Update Date: 09/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2330 SIOUX TRAIL NW
PRIOR LAKE MN
55372
US

IV. Provider business mailing address

8033 JOCELYN AVE S
COTTAGE GROVE MN
55016
US

V. Phone/Fax

Practice location:
  • Phone: 952-496-6150
  • Fax:
Mailing address:
  • Phone: 651-707-6130
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5160
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: