Provider Demographics
NPI:1932109980
Name:GOMES, MARIA DE LOURDES AZEVEDO (MD)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:DE LOURDES AZEVEDO
Last Name:GOMES
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 1:2800 CAMPUS DR
Mailing Address - Street 2:STE 10
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55441-2645
Mailing Address - Country:US
Mailing Address - Phone:763-559-2171
Mailing Address - Fax:763-694-9000
Practice Address - Street 1:3300 OAKDALE AVE N
Practice Address - Street 2:
Practice Address - City:ROBBINSDALE
Practice Address - State:MN
Practice Address - Zip Code:55422-2926
Practice Address - Country:US
Practice Address - Phone:763-559-2171
Practice Address - Fax:763-694-9000
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2012-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN405532085R0202X, 2085R0204X, 2085B0100X, 2085N0904X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN993017500Medicaid
MN993017500Medicaid
300003062Medicare ID - Type Unspecified