Provider Demographics
NPI:1780689539
Name:EGGLESTON, KATHRYN (MD)
Entity Type:Individual
Prefix:DR
First Name:KATHRYN
Middle Name:
Last Name:EGGLESTON
Suffix:
Gender:F
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:PO BOX 14826
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55414-0826
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1965 FORD PKWY
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55116-1923
Practice Address - Country:US
Practice Address - Phone:651-696-5520
Practice Address - Fax:612-375-9567
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2020-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAMD-47063207Q00000X
MN43137207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN138488100Medicaid
MNG88210Medicare UPIN
MN138488100Medicaid