Provider Demographics
NPI:1265463129
Name:FENYK, JOHN RAYMOND JR (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:RAYMOND
Last Name:FENYK
Suffix:JR
Gender:M
Credentials:MD
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Mailing Address - Street 1:516 DELAWARE ST SE
Mailing Address - Street 2:MMC 98
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55455-0356
Mailing Address - Country:US
Mailing Address - Phone:612-625-5656
Mailing Address - Fax:612-624-6678
Practice Address - Street 1:516 DELAWARE ST SE
Practice Address - Street 2:MMC 98
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455-0356
Practice Address - Country:US
Practice Address - Phone:612-625-5656
Practice Address - Fax:612-624-6678
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2008-06-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN23247207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN0716001OtherPREFERRED ONE
MNHP13270OtherHEALTHPARTNERS
MN03-03331OtherMEDICA CHOICE
MN03-00003OtherMEDICA PRIMARY
MN411436271001OtherCHAMPUS
MNOG471FEOtherBCBS
MN305893000Medicaid
MNB84837Medicare UPIN
MN0716001OtherPREFERRED ONE
MN411436271001OtherCHAMPUS