Provider Demographics
NPI:1447200605
Name:CONKLIN, PETER (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:
Last Name:CONKLIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:4801 W 81ST ST
Mailing Address - Street 2:SUITE 108
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55437-1111
Mailing Address - Country:US
Mailing Address - Phone:952-837-9700
Mailing Address - Fax:952-837-9701
Practice Address - Street 1:250 THOMPSON ST
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-2370
Practice Address - Country:US
Practice Address - Phone:651-292-2000
Practice Address - Fax:651-292-2136
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2019-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN318242085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN673307700Medicaid