Provider Demographics
NPI:1003836800
Name:NUTZ, DAVID J (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:J
Last Name:NUTZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8170 33RD AVE S # MS 21110Q
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3800 PARK NICOLLET BLVD
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-2527
Practice Address - Country:US
Practice Address - Phone:952-993-3800
Practice Address - Fax:952-993-1392
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN102549208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN073493000Medicaid
MN250000708Medicare ID - Type Unspecified
MN073493000Medicaid