Provider Demographics
NPI:1790796761
Name:CHESTOVICH, MICHELLE W (MD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:W
Last Name:CHESTOVICH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:WENNER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2025 SLOAN PL STE 35
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55117-2092
Mailing Address - Country:US
Mailing Address - Phone:651-772-1572
Mailing Address - Fax:651-772-1889
Practice Address - Street 1:234 WENTWORTH AVE E
Practice Address - Street 2:
Practice Address - City:WEST ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55118-3525
Practice Address - Country:US
Practice Address - Phone:651-455-2940
Practice Address - Fax:651-455-3354
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2019-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN44933207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN377170900Medicaid
H78843Medicare UPIN