Provider Demographics
NPI:1104866847
Name:PAZDERNIK, JULIE A (MD)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:A
Last Name:PAZDERNIK
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 1:1027 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56501-3409
Mailing Address - Country:US
Mailing Address - Phone:218-847-5611
Mailing Address - Fax:218-847-0881
Practice Address - Street 1:1027 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:DETROIT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56501-3409
Practice Address - Country:US
Practice Address - Phone:218-847-5611
Practice Address - Fax:218-847-0881
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2011-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN46487207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN41518OtherLHS/BANNERHEALTH #
MNDA9031041396OtherPREFERRED ONE #
MNHP42890OtherHEALTHPARTNERS #
MN13069Medicaid
MN489R3PAOtherMNBS #
MN181766OtherUCARE #
MN2141911OtherAMERICA'S PPO/ARAZ #
MN0120544OtherMEDICA #
MN906427300Medicaid
MN25565OtherNDBS #
MN489R3PAOtherMNBS #
MN906427300Medicaid
MNDA9031041396OtherPREFERRED ONE #