Provider Demographics
NPI:1538129283
Name:WERTWIJN, RALPH D (MD)
Entity Type:Individual
Prefix:
First Name:RALPH
Middle Name:D
Last Name:WERTWIJN
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 1:2023 LINN DR
Mailing Address - Street 2:
Mailing Address - City:OWATONNA
Mailing Address - State:MN
Mailing Address - Zip Code:55060-4212
Mailing Address - Country:US
Mailing Address - Phone:507-455-0067
Mailing Address - Fax:
Practice Address - Street 1:2023 LINN DR
Practice Address - Street 2:
Practice Address - City:OWATONNA
Practice Address - State:MN
Practice Address - Zip Code:55060-4212
Practice Address - Country:US
Practice Address - Phone:507-455-0067
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-26
Last Update Date:2010-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN30544207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN491383300Medicaid
110004100Medicare ID - Type Unspecified
MN491383300Medicaid