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General NPI Number Information
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NPI Number | 1487601316
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Entity Type | Individual
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Provider Name | JACK LEON-MAX MUTNICK M.D.
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Gender | Male
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Dates
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Enumeration Date | 05/27/2006
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Last Update Date | 12/11/2024
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Provider Practice Location Address
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Address Line | 3939 W 69TH ST STE A
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City | EDINA
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State | MN
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Zip | 55435-2001
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Country | US
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Telephone | 612-930-8462
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Fax | 800-785-5608
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Provider Business Mailing Address
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Address Line | 3440 MOLINA ST
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City | SHAKOPEE
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State | MN
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Zip | 55379-5444
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Country | US
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Telephone | 714-296-6777
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Fax | 800-785-5608
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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 | 207K00000X
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Taxonomy Name | Allergy & Immunology Physician
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License Number | 48180
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 48180
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License Number State | MN
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