Provider Demographics
NPI:1760473615
Name:HUMBERT, JEFFREY THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:THOMAS
Last Name:HUMBERT
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 1:14001 RIDGEDALE DR STE 100
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55305-1781
Mailing Address - Country:US
Mailing Address - Phone:952-473-0211
Mailing Address - Fax:952-473-7908
Practice Address - Street 1:111 HUNDERTMARK RD STE 420
Practice Address - Street 2:
Practice Address - City:CHASKA
Practice Address - State:MN
Practice Address - Zip Code:55318-1459
Practice Address - Country:US
Practice Address - Phone:952-448-3847
Practice Address - Fax:952-448-5083
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2017-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN45232208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
300K7HUOtherBLUE CROSS BLUE SHIELD
HP41441OtherHEALTH PARTNERS
1040719OtherPREFERRED ONE
1202922OtherMEDICA HEALTH PLANS
50A61CEOtherBLUE CROSS BLUE SHIELD
2121658OtherARAZ GROUP AMERICAS PPO
300K6HUOtherBLUE CROSS BLUE SHIELD
50A45CEOtherBLUE CROSS BLUE SHIELD
782673700OtherMEDICAL ASSISTANCE
131391OtherUCARE
300K7HUOtherBLUE CROSS BLUE SHIELD
C02303Medicare ID - Type Unspecified
370002912Medicare ID - Type Unspecified