Provider Demographics
NPI:1033606157
Name:KUTZ, BROOKE ALEXANDRA (MD)
Entity Type:Individual
Prefix:DR
First Name:BROOKE
Middle Name:ALEXANDRA
Last Name:KUTZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:BROOKE
Other - Middle Name:ALEXANDRA
Other - Last Name:JENSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:10689 SONOMA RDG
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55347-1169
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1414 MARYLAND AVE E
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55106-2824
Practice Address - Country:US
Practice Address - Phone:651-772-3461
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-14
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MN68573208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program