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NPI Code Detail

MEDICARE: DR. FREDERICK MAST DULA JR. MD

MEDICARE: DR. FREDERICK MAST DULA JR. MD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
12085R0202XDiagnostic Radiology Physician26625NC

General Provider Information

NPI Number : 1104821412
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. FREDERICK MAST DULA JR. MD
Provider Business Mailing Address
First Line : 11995 SINGLETREE LN STE 500
Second Line :
City : EDEN PRAIRIE
State : MN
Zip : 55344-5349
Country : US
Telephone Number : 952-595-1301
Fax Number : 612-294-4903
Provider Business Practice Location Address
First Line : 3623 LATROBE DR STE 216
Second Line :
City : CHARLOTTE
State : NC
Zip : 28211-2117
Country : US
Telephone Number : 704-332-1291
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/15/2005
Last Update Date : 03/27/2024

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