Provider Demographics
NPI:1073648259
Name:LUISTRO, ALLAN JAMES (MD)
Entity Type:Individual
Prefix:DR
First Name:ALLAN
Middle Name:JAMES
Last Name:LUISTRO
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:5027 ROSE CREEK PKWY S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-6848
Mailing Address - Country:US
Mailing Address - Phone:701-298-9024
Mailing Address - Fax:701-297-0132
Practice Address - Street 1:1104 7TH AVE S.
Practice Address - Street 2:BOX 92 MSUM HENDRIX CLINIC & COUNSELING CENTER
Practice Address - City:MOORHEAD
Practice Address - State:MN
Practice Address - Zip Code:56563
Practice Address - Country:US
Practice Address - Phone:218-477-2211
Practice Address - Fax:218-477-5867
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2012-02-22
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Provider Licenses
StateLicense IDTaxonomies
MN37656207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN804733200Medicaid
ND17256Medicaid
MN804733200Medicaid