Provider Demographics
NPI:1598765877
Name:MOELLER, MICHAEL L (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:L
Last Name:MOELLER
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 1:600 REED ST
Mailing Address - Street 2:SUITE 115
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-6410
Mailing Address - Country:US
Mailing Address - Phone:507-625-4060
Mailing Address - Fax:
Practice Address - Street 1:600 REED ST
Practice Address - Street 2:SUITE 115
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-6410
Practice Address - Country:US
Practice Address - Phone:507-625-4060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-28
Last Update Date:2012-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN395842084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNHP24849OtherHEALTH PARTNERS
MN531214100Medicaid
MN122727D113OtherU CARE OF MINNESOTA
MN359J1MOOtherBLUE CROSS BLUE SHIELD
MN260002227Medicare ID - Type Unspecified
MNHP24849OtherHEALTH PARTNERS