Provider Demographics
NPI:1750478319
Name:FUGLESTAD, DAVID E (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:E
Last Name:FUGLESTAD
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 1:8559 EDINBROOK PKWY
Mailing Address - Street 2:STE 100
Mailing Address - City:BROOKLYN PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55443-3747
Mailing Address - Country:US
Mailing Address - Phone:763-425-1888
Mailing Address - Fax:
Practice Address - Street 1:8559 EDINBROOK PKWY
Practice Address - Street 2:STE 100
Practice Address - City:BROOKLYN PARK
Practice Address - State:MN
Practice Address - Zip Code:55443-3747
Practice Address - Country:US
Practice Address - Phone:763-425-1888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN33521207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN80002572Medicare ID - Type Unspecified
F43959Medicare UPIN