Healthcare Provider Details

I. General information

NPI: 1609878446
Provider Name (Legal Business Name): JOHN D MISCHKE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/11/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 6TH AVE N
SAINT CLOUD MN
56303-2735
US

IV. Provider business mailing address

1200 6TH AVE N
SAINT CLOUD MN
56303-2735
US

V. Phone/Fax

Practice location:
  • Phone: 320-252-5131
  • Fax: 320-240-2118
Mailing address:
  • Phone: 320-252-5131
  • Fax: 320-240-2118

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number35762
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: