Provider Demographics
NPI:1760747562
Name:THEISEN, JOSHUA WILLIAM MARVIN (MD-PHD)
Entity Type:Individual
Prefix:DR
First Name:JOSHUA
Middle Name:WILLIAM MARVIN
Last Name:THEISEN
Suffix:
Gender:M
Credentials:MD-PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2450 RIVERSIDE AVENUE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55454-1450
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2450 RIVERSIDE AVENUE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55454-1002
Practice Address - Country:US
Practice Address - Phone:612-365-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-08
Last Update Date:2018-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012020973208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics