Healthcare Provider Details

I. General information

NPI: 1609132125
Provider Name (Legal Business Name): ROULA ALTISHEH M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2012
Last Update Date: 09/19/2024
Certification Date: 09/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 PHALEN BLVD
SAINT PAUL MN
55130-5302
US

IV. Provider business mailing address

8170 33RD AVE S MS 21110Q
BLOOMINGTON MN
55425-4516
US

V. Phone/Fax

Practice location:
  • Phone: 651-254-7560
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number35.134068
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number73925
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: