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General NPI Number Information
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NPI Number | 1073648259
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Entity Type | Individual
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Provider Name | ALLAN JAMES LUISTRO M.D.
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Gender | Male
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Dates
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Enumeration Date | 02/21/2007
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Last Update Date | 02/22/2012
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Provider Practice Location Address
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Address Line | 1104 7TH AVE S. BOX 92 MSUM HENDRIX CLINIC & COUNSELING CENTER
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City | MOORHEAD
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State | MN
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Zip | 56563
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Country | US
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Telephone | 218-477-2211
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Fax | 218-477-5867
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Provider Business Mailing Address
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Address Line | 5027 ROSE CREEK PKWY S
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City | FARGO
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State | ND
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Zip | 58104-6848
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Country | US
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Telephone | 701-298-9024
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Fax | 701-297-0132
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 37656
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License Number State | MN
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