Provider Demographics
NPI:1184692279
Name:MIELKE, DEBORAH KIM (MD)
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:KIM
Last Name:MIELKE
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 1:409 N. DUNLAP STREET
Mailing Address - Street 2:
Mailing Address - City:ST. PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104
Mailing Address - Country:US
Mailing Address - Phone:651-290-9200
Mailing Address - Fax:651-290-9201
Practice Address - Street 1:409 N. DUNLAP ST.
Practice Address - Street 2:OPEN CITIES HEALTH CENTER
Practice Address - City:ST. PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104
Practice Address - Country:US
Practice Address - Phone:651-290-9200
Practice Address - Fax:651-290-9201
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2013-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN28770207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN341875800Medicaid
D80024Medicare UPIN