Provider Demographics
NPI:1831321785
Name:DOMINGO MUSIBAY, EVIDIO (MD)
Entity Type:Individual
Prefix:
First Name:EVIDIO
Middle Name:
Last Name:DOMINGO MUSIBAY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:EVIDIO
Other - Middle Name:
Other - Last Name:DOMINGO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2925 CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-1321
Mailing Address - Country:US
Mailing Address - Phone:612-262-9000
Mailing Address - Fax:612-262-9035
Practice Address - Street 1:800 E 28TH ST STE 401
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407-3723
Practice Address - Country:US
Practice Address - Phone:612-863-0200
Practice Address - Fax:612-863-0235
Is Sole Proprietor?:No
Enumeration Date:2009-08-11
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN52977207RH0000X, 207RX0202X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
No207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNP01075996OtherRAIL ROAD - MEDICARE
MNENROLLEDMedicaid
IAENROLLEDMedicaid
MNENROLLEDMedicaid