Provider Demographics
NPI:1306832464
Name:CERVENKA, RICHARD PETER (DPM)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:PETER
Last Name:CERVENKA
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3790 117TH LN NW
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-2666
Mailing Address - Country:US
Mailing Address - Phone:763-421-7300
Mailing Address - Fax:763-421-3337
Practice Address - Street 1:3790 117TH LN NW
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-2666
Practice Address - Country:US
Practice Address - Phone:763-421-7300
Practice Address - Fax:763-421-3337
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2017-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN304213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN042325400Medicaid
MN34039CEOtherBC
0196780001Medicare NSC
MN042325400Medicaid
MN2700252Medicare UPIN
MN480000413Medicare ID - Type Unspecified