Provider Demographics
NPI:1689857955
Name:KIM D FJELSTAD DPM PA
Entity Type:Organization
Organization Name:KIM D FJELSTAD DPM PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KIM
Authorized Official - Middle Name:DARYL
Authorized Official - Last Name:FJELSTAD
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:952-435-2629
Mailing Address - Street 1:14000 NICOLLET AVE
Mailing Address - Street 2:306
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-5790
Mailing Address - Country:US
Mailing Address - Phone:952-435-2629
Mailing Address - Fax:952-435-2650
Practice Address - Street 1:14000 NICOLLET AVE
Practice Address - Street 2:306
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-5790
Practice Address - Country:US
Practice Address - Phone:952-435-2629
Practice Address - Fax:952-435-2650
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-10
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN410213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN913525100Medicaid
MN913525100Medicaid
MN913525100Medicaid
MN480000113Medicare PIN
MNT39518Medicare UPIN
MN6153450001Medicare NSC