Provider Demographics
NPI:1679545453
Name:MOELLER, KAREN A (MD)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:A
Last Name:MOELLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8100 34TH AVE S
Mailing Address - Street 2:MC21110Q
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-1672
Mailing Address - Country:US
Mailing Address - Phone:123-123-1234
Mailing Address - Fax:763-287-5019
Practice Address - Street 1:640 JACKSON ST
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55101-2502
Practice Address - Country:US
Practice Address - Phone:123-123-1234
Practice Address - Fax:763-287-5019
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2008-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN42006207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN263605100Medicaid
MN263605100Medicaid
H12746Medicare UPIN