Healthcare Provider Details

I. General information

NPI: 1700858081
Provider Name (Legal Business Name): THOMAS J YACOVELLA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2006
Last Update Date: 08/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 JACKSON ST
SAINT PAUL MN
55101-2502
US

IV. Provider business mailing address

8100 34TH AVE S MC21110Q
BLOOMINGTON MN
55425-1672
US

V. Phone/Fax

Practice location:
  • Phone: 123-123-1234
  • Fax: 651-254-3662
Mailing address:
  • Phone: 123-123-1234
  • Fax: 651-254-3662

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number38588
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: