Provider Demographics
NPI:1093780934
Name:NESHEIM, MIRTHA (MD)
Entity Type:Individual
Prefix:
First Name:MIRTHA
Middle Name:
Last Name:NESHEIM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9800 ROCKFORD RD
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55442-2811
Mailing Address - Country:US
Mailing Address - Phone:763-559-0092
Mailing Address - Fax:763-559-9404
Practice Address - Street 1:12000 ELM CREEK BLVD N
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-7073
Practice Address - Country:US
Practice Address - Phone:763-420-5822
Practice Address - Fax:763-420-6387
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN46595207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNI04374Medicare UPIN