Provider Demographics
NPI:1639152150
Name:VIRANT, JEFFREY LOUIS (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:LOUIS
Last Name:VIRANT
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 1:1500 CURVE CREST BVLD W
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082-6040
Mailing Address - Country:US
Mailing Address - Phone:651-439-1234
Mailing Address - Fax:651-439-1547
Practice Address - Street 1:1500 CURVE CREST BLVD W
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-6040
Practice Address - Country:US
Practice Address - Phone:651-439-1234
Practice Address - Fax:651-439-1547
Is Sole Proprietor?:No
Enumeration Date:2005-11-29
Last Update Date:2011-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN25299207Q00000X
WI41029207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN694802200Medicaid
WI30378000Medicaid
P00202259Medicare PIN
MNA94152Medicare UPIN
WI001556150Medicare PIN
MN694802200Medicaid