Provider Demographics
NPI:1598756041
Name:JUSTESEN, KATHRYN G (MD)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:G
Last Name:JUSTESEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5502 W BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL
Mailing Address - State:MN
Mailing Address - Zip Code:55428-3508
Mailing Address - Country:US
Mailing Address - Phone:763-504-6500
Mailing Address - Fax:763-504-6544
Practice Address - Street 1:5502 W BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:CRYSTAL
Practice Address - State:MN
Practice Address - Zip Code:55428-3508
Practice Address - Country:US
Practice Address - Phone:763-504-6500
Practice Address - Fax:763-504-6544
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2010-06-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN42665207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN762695900Medicaid
MNH22664Medicare UPIN
MN762695900Medicaid