Provider Demographics
NPI:1083694897
Name:FUGLESTAD, STEVEN JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:JOHN
Last Name:FUGLESTAD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2755 COUNTY ROAD 19
Mailing Address - Street 2:
Mailing Address - City:MAPLE PLAIN
Mailing Address - State:MN
Mailing Address - Zip Code:55359-9659
Mailing Address - Country:US
Mailing Address - Phone:763-479-3684
Mailing Address - Fax:
Practice Address - Street 1:1013 HART BLVD
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:MN
Practice Address - Zip Code:55362-8575
Practice Address - Country:US
Practice Address - Phone:763-271-2248
Practice Address - Fax:763-271-2890
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN32490207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNF68270Medicare UPIN