Healthcare Provider Details

I. General information

NPI: 1174176333
Provider Name (Legal Business Name): LAITH AL EJEILAT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2019
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

153 CESAR CHAVEZ ST
SAINT PAUL MN
55107-2226
US

IV. Provider business mailing address

153 CESAR CHAVEZ ST
SAINT PAUL MN
55107-2226
US

V. Phone/Fax

Practice location:
  • Phone: 651-602-7500
  • Fax: 651-602-7513
Mailing address:
  • Phone: 651-602-7500
  • Fax: 651-602-7513

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number82876
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: