Healthcare Provider Details

I. General information

NPI: 1780505032
Provider Name (Legal Business Name): MIGUEL JOSE JAVILLONAR CID MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2026
Last Update Date: 07/23/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4840 23RD AVE S
FARGO ND
58104-9136
US

IV. Provider business mailing address

4840 23RD AVE S
FARGO ND
58104-9136
US

V. Phone/Fax

Practice location:
  • Phone: 701-234-8840
  • Fax:
Mailing address:
  • Phone: 701-234-8840
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberRL24358
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: