Provider Demographics
NPI:1659491090
Name:KVISTAD, BONNIE S (MD)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:S
Last Name:KVISTAD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2701 13TH AVE S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-3602
Mailing Address - Country:US
Mailing Address - Phone:701-234-3620
Mailing Address - Fax:
Practice Address - Street 1:2701 13TH AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-3602
Practice Address - Country:US
Practice Address - Phone:701-234-3620
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDPT11205208000000X
MN49784208000000X
ND11205208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN724690000Medicaid
MN724690000Medicaid
NDN714364Medicare PIN