Provider Demographics
NPI:1407818016
Name:FUGLESTAD, EDSON VERCEL (MD)
Entity Type:Individual
Prefix:DR
First Name:EDSON
Middle Name:VERCEL
Last Name:FUGLESTAD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:6401 UNIVERSITY AVE NE
Mailing Address - Street 2:
Mailing Address - City:FRIDLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55432-4341
Mailing Address - Country:US
Mailing Address - Phone:763-572-5710
Mailing Address - Fax:763-571-3008
Practice Address - Street 1:6341 UNIVERSITY AVE NE
Practice Address - Street 2:
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432-4946
Practice Address - Country:US
Practice Address - Phone:763-572-5710
Practice Address - Fax:763-586-5888
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN15811207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1000846OtherPREFERRED ONE
MN107289OtherUCARE MN
MN6603881OtherMEDICA UC
MN4044532OtherAETNA
MN0108771OtherMEDICA
MN1692254OtherAMERICA'S PPO
MN66G04FUOtherBCBS OF MN
MNHP36120OtherHEALTHPARTNERS
MN107289OtherUCARE MN