Provider Demographics
NPI:1265952907
Name:RONSTROM, CARRIE (MD)
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:
Last Name:RONSTROM
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 1:1001 E SUPERIOR ST STE 201
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55802-2228
Mailing Address - Country:US
Mailing Address - Phone:218-249-5555
Mailing Address - Fax:
Practice Address - Street 1:1001 E SUPERIOR ST STE 201
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55802-2228
Practice Address - Country:US
Practice Address - Phone:218-249-5555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-23
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017020629208800000X
MN71495208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology