Provider Demographics
NPI:1619363546
Name:LEBEDOFF, NICHOLAS (MD)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:LEBEDOFF
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 1:7600 FRANCE AVE S STE 5100
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-6026
Mailing Address - Country:US
Mailing Address - Phone:952-832-0246
Mailing Address - Fax:952-893-1954
Practice Address - Street 1:7600 FRANCE AVE S STE 5100
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-6026
Practice Address - Country:US
Practice Address - Phone:952-832-0246
Practice Address - Fax:952-893-1954
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-07
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MN67851207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program