Healthcare Provider Details

I. General information

NPI: 1912015942
Provider Name (Legal Business Name): JOHN W MECCIA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 05/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

490 S MAPLE ST SUITE 205
WACONIA MN
55387-1760
US

IV. Provider business mailing address

490 S MAPLE ST SUITE 205
WACONIA MN
55387-1760
US

V. Phone/Fax

Practice location:
  • Phone: 952-925-5626
  • Fax:
Mailing address:
  • Phone: 952-925-5626
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0901X
TaxonomyOtology & Neurotology Physician
License Number38257
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: