=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235340894
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KAMRUZ DARABI M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/25/2007
-----------------------------------------------------
Last Update Date | 12/21/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 582 CHERRY DR
-----------------------------------------------------
City | WACONIA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55387-4578
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-395-6850
-----------------------------------------------------
Fax | 952-395-6870
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 582 CHERRY DR
-----------------------------------------------------
City | WACONIA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55387-4578
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-395-6850
-----------------------------------------------------
Fax | 952-395-6870
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207ND0101X
-----------------------------------------------------
Taxonomy Name | MOHS-Micrographic Surgery Physician
-----------------------------------------------------
License Number | 55882
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207ND0900X
-----------------------------------------------------
Taxonomy Name | Dermatopathology Physician
-----------------------------------------------------
License Number | 55882
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number | 55882
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------