Healthcare Provider Details

I. General information

NPI: 1538277314
Provider Name (Legal Business Name): ROBERT H DYBVIG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 03/16/2021
Certification Date: 03/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 CURVE CREST BLVD W
STILLWATER MN
55082-6040
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 651-439-1234
  • Fax: 651-275-3325
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number31710
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: