Provider Demographics
NPI:1689867129
Name:BOKSBERGER, TERRY (DO)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:
Last Name:BOKSBERGER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8170 33RD AVE S
Mailing Address - Street 2:PO BOX 1309 MAIL STOP 21110Q
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:952-993-8250
Mailing Address - Fax:
Practice Address - Street 1:250 CENTRAL AVE N
Practice Address - Street 2:SUITE 228
Practice Address - City:WAYZATA
Practice Address - State:MN
Practice Address - Zip Code:55391-1206
Practice Address - Country:US
Practice Address - Phone:952-993-8250
Practice Address - Fax:952-993-8276
Is Sole Proprietor?:No
Enumeration Date:2007-08-18
Last Update Date:2016-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101016814207Q00000X
MN107105207Q00000X
NC2011-00868207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5919235Medicaid
NC5919235Medicaid