Healthcare Provider Details

I. General information

NPI: 1962931451
Provider Name (Legal Business Name): KARL KOIVISTO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2017
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 CENTRACARE CIR STE 2650
SAINT CLOUD MN
56303-5000
US

IV. Provider business mailing address

1700 UNIVERSITY AVE W FL 6
SAINT PAUL MN
55104-3727
US

V. Phone/Fax

Practice location:
  • Phone: 320-253-2663
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PS0010X
TaxonomySports Medicine (Emergency Medicine) Physician
License Number67132
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code207PS0010X
TaxonomySports Medicine (Emergency Medicine) Physician
License Number13846498-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: