Provider Demographics
NPI:1003811464
Name:KYLLO, DAVID STUART (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:STUART
Last Name:KYLLO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3460 WASHINGTON DR
Mailing Address - Street 2:STE 102
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55122-4301
Mailing Address - Country:US
Mailing Address - Phone:651-452-9240
Mailing Address - Fax:651-452-5440
Practice Address - Street 1:3460 WASHINGTON DR
Practice Address - Street 2:STE 102
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55122-4301
Practice Address - Country:US
Practice Address - Phone:651-452-9240
Practice Address - Fax:651-452-5440
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-14
Last Update Date:2007-07-08
Deactivation Date:2006-03-17
Deactivation Code:
Reactivation Date:2006-03-22
Provider Licenses
StateLicense IDTaxonomies
MN25450207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNA95834Medicare UPIN