Provider Demographics
NPI:1912044918
Name:DAVENPORT, SANDRA LOUISE HYVARINEN (MD)
Entity Type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:LOUISE HYVARINEN
Last Name:DAVENPORT
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 1:6109 W 105TH ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55438-1833
Mailing Address - Country:US
Mailing Address - Phone:952-831-5522
Mailing Address - Fax:952-831-0381
Practice Address - Street 1:6109 W 105TH ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55438-1833
Practice Address - Country:US
Practice Address - Phone:952-831-5522
Practice Address - Fax:952-831-0381
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2013-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN29543207SG0201X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN2034451Medicaid
MN2034451Medicaid
MN370000346Medicare ID - Type Unspecified