Provider Demographics
NPI:1124003751
Name:SMITH, PENELOPE JUVRUD (MD)
Entity Type:Individual
Prefix:
First Name:PENELOPE
Middle Name:JUVRUD
Last Name:SMITH
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 1:8170 33RD AVE S # MS 21110Q
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14701 VICTOR HUGO BLVD N
Practice Address - Street 2:
Practice Address - City:HUGO
Practice Address - State:MN
Practice Address - Zip Code:55038-4561
Practice Address - Country:US
Practice Address - Phone:952-853-8800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN41726207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN080149404OtherMEDICARE RAILROAD
MN024217900Medicaid
MN080149404OtherMEDICARE RAILROAD
MN080009794Medicare ID - Type Unspecified