Provider Demographics
NPI:1134295264
Name:SCHANDORF, WINSTON STEPHEN
Entity Type:Individual
Prefix:
First Name:WINSTON
Middle Name:STEPHEN
Last Name:SCHANDORF
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 NINTH STREET NORTH
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA
Mailing Address - State:MN
Mailing Address - Zip Code:55792-2398
Mailing Address - Country:US
Mailing Address - Phone:218-741-3340
Mailing Address - Fax:218-749-9427
Practice Address - Street 1:901 NINTH STREET NORTH
Practice Address - Street 2:
Practice Address - City:VIRGINIA
Practice Address - State:MN
Practice Address - Zip Code:55792-2398
Practice Address - Country:US
Practice Address - Phone:218-741-3340
Practice Address - Fax:218-749-9427
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2011-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN29830207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN140280300Medicaid
MN140280300Medicaid
MN110005125Medicare ID - Type Unspecified