Provider Demographics
NPI:1841388964
Name:OAKDALE FAMILY PRACTICE, PC
Entity Type:Organization
Organization Name:OAKDALE FAMILY PRACTICE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GENE
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:VELASCO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:763-529-9131
Mailing Address - Street 1:3366 OAKDALE AVE N
Mailing Address - Street 2:SUITE 403
Mailing Address - City:ROBBINSDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55422-2948
Mailing Address - Country:US
Mailing Address - Phone:763-529-9131
Mailing Address - Fax:763-529-5519
Practice Address - Street 1:3366 OAKDALE AVE N
Practice Address - Street 2:SUITE 403
Practice Address - City:ROBBINSDALE
Practice Address - State:MN
Practice Address - Zip Code:55422-2948
Practice Address - Country:US
Practice Address - Phone:763-529-9131
Practice Address - Fax:763-529-5519
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN24D0670882261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CH8589OtherRAILROAD MEDICARE
MNNA376OtherPREFERRED ONE
MN767798700Medicaid
487659600OtherDEPT OF LABOR
MNP153OtherUCARE
MN06744HAOtherBCBS MN
MN767798700Medicaid