Provider Demographics
NPI:1770500555
Name:MISSELT, ANDREW JAMES (MD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:JAMES
Last Name:MISSELT
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 1:8170 33RD AVE S # MS 21110Q
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3850 PARK NICOLLET BLVD
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-2527
Practice Address - Country:US
Practice Address - Phone:952-993-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN487062085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1047281OtherPREFERRED ONE
MN1770500555OtherAMERICA'S PPO
MN300003980OtherMEDICARE
MNHP65836OtherHEALTHPARTNERS
MN1604206OtherMEDICA
MNP00332886OtherRAILROAD MEDICARE
MN814T2MIOtherBLUE CROSS BLUE SHIELD
133246OtherUCARE
MN872600100Medicaid
MN300003981OtherMEDICARE
MN1047281OtherPREFERRED ONE
MN300004185Medicare PIN