Healthcare Provider Details

I. General information

NPI: 1598586182
Provider Name (Legal Business Name): DR. JOSEPH MBITHI MUTUA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2024
Last Update Date: 10/17/2024
Certification Date: 10/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1815 SUBURBAN AVE STE 101
SAINT PAUL MN
55119-4398
US

IV. Provider business mailing address

2331 DAHL AVE E
MAPLEWOOD MN
55119-5831
US

V. Phone/Fax

Practice location:
  • Phone: 651-815-1057
  • Fax:
Mailing address:
  • Phone: 651-815-1057
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License NumberN504-125-499-209
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: