Provider Demographics
NPI:1457322802
Name:PAULSON, JOHN ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ROBERT
Last Name:PAULSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17705 HUTCHINS DR
Mailing Address - Street 2:#101
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55345-4145
Mailing Address - Country:US
Mailing Address - Phone:952-401-8300
Mailing Address - Fax:
Practice Address - Street 1:12000 ELM CREEK BLVD N
Practice Address - Street 2:#250
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-7073
Practice Address - Country:US
Practice Address - Phone:952-401-8300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN38883208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN111714OtherUCARE
MN1208118OtherMEDICA
MN32Y76PAOtherBLUECROSS
MNCP9041011314OtherPREFERRED ONE
MN32Y76PAOtherBLUECROSS