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General NPI Number Information
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NPI Number | 1841964277
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Entity Type | Organization
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Legal Business Name | WOODBURY ENDOCRINOLOGY AND DIABETES CLINIC LLC
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Dates
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Enumeration Date | 08/09/2021
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Last Update Date | 03/04/2022
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Provider Practice Location Address
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Address Line | 539 BIELENBERG DR STE 120
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City | WOODBURY
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State | MN
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Zip | 55125-4437
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Country | US
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Telephone | 612-425-0958
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Fax | 651-340-4233
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Provider Business Mailing Address
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Address Line | 539 BIELENBERG DR STE 120
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City | WOODBURY
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State | MN
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Zip | 55125-4437
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Country | US
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Telephone | 612-425-0958
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Fax | 651-340-4233
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Authorized Official
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Title or Position | CEO
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Name | DR. ABEL ALFONSO
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Credential | DO
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Telephone | 612-425-0958
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number |
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License Number State |
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