Provider Demographics
NPI:1629304738
Name:RUIZ ESPONDA, RAUL (MD)
Entity Type:Individual
Prefix:
First Name:RAUL
Middle Name:
Last Name:RUIZ ESPONDA
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:PO BOX 2168
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58107-2168
Mailing Address - Country:US
Mailing Address - Phone:701-234-2119
Mailing Address - Fax:
Practice Address - Street 1:2400 32ND AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-5800
Practice Address - Country:US
Practice Address - Phone:701-234-7980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-23
Last Update Date:2015-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10034527207R00000X
MN106359207RE0101X
MN55770207RE0101X
ND13600207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNP01114334OtherMEDICARE RAILROAD
MNP01114334OtherMEDICARE RAILROAD
MN460000447Medicare PIN
NDN721746Medicare PIN