Healthcare Provider Details

I. General information

NPI: 1275024663
Provider Name (Legal Business Name): MARY CATHERINE MOHR DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2018
Last Update Date: 10/18/2021
Certification Date: 10/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4786 BANNING AVE
WHITE BEAR LAKE MN
55110-3264
US

IV. Provider business mailing address

2025 SLOAN PL STE 35
SAINT PAUL MN
55117-2092
US

V. Phone/Fax

Practice location:
  • Phone: 651-426-6402
  • Fax: 651-429-3402
Mailing address:
  • Phone: 651-772-1572
  • Fax: 651-772-1889

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number70152
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR-11163
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: