Healthcare Provider Details

I. General information

NPI: 1164779211
Provider Name (Legal Business Name): MICHAEL RAYMOND MOYNAGH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2012
Last Update Date: 08/18/2020
Certification Date: 08/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 1ST ST SW
ROCHESTER MN
55905-0001
US

IV. Provider business mailing address

200 1ST ST SW
ROCHESTER MN
55905-0001
US

V. Phone/Fax

Practice location:
  • Phone: 507-284-2511
  • Fax:
Mailing address:
  • Phone: 507-284-2511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number58416
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: