Provider Demographics
NPI:1467429621
Name:ITO, MARI B (MD)
Entity Type:Individual
Prefix:DR
First Name:MARI
Middle Name:B
Last Name:ITO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MARI
Other - Middle Name:
Other - Last Name:ITO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:2925 CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-1321
Mailing Address - Country:US
Mailing Address - Phone:612-262-1166
Mailing Address - Fax:
Practice Address - Street 1:9055 SPRINGBROOK DR NW
Practice Address - Street 2:URGENCY CARE
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-5841
Practice Address - Country:US
Practice Address - Phone:763-236-7144
Practice Address - Fax:763-236-7733
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2015-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN33781207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN539500300Medicaid
MN33781OtherMN MEDICAL LICENSE
MN539500300Medicaid
MN539500300Medicaid