Provider Demographics
NPI:1043284268
Name:SMULKA, ROMAN P (MD)
Entity Type:Individual
Prefix:
First Name:ROMAN
Middle Name:P
Last Name:SMULKA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:15245 BLUEBIRD ST NW
Mailing Address - Street 2:
Mailing Address - City:ANOKA
Mailing Address - State:MN
Mailing Address - Zip Code:55304-3538
Mailing Address - Country:US
Mailing Address - Phone:763-587-4600
Mailing Address - Fax:763-587-4615
Practice Address - Street 1:15245 BLUEBIRD ST NW
Practice Address - Street 2:MAIL STOP 39200A RIVERWAY CLINIC - ANDOVER
Practice Address - City:ANDOVER
Practice Address - State:MN
Practice Address - Zip Code:55304-3554
Practice Address - Country:US
Practice Address - Phone:763-587-4600
Practice Address - Fax:763-587-4615
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2013-01-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN27033207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN668585400Medicaid
D81166Medicare UPIN
MN668585400Medicaid