Provider Demographics
NPI:1356335467
Name:RAGAB, MIRIAM V (DO)
Entity type:Individual
Prefix:
First Name:MIRIAM
Middle Name:V
Last Name:RAGAB
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5001 AMERICAN BLVD W
Mailing Address - Street 2:STE 945
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55437-1162
Mailing Address - Country:US
Mailing Address - Phone:952-835-6653
Mailing Address - Fax:952-835-3895
Practice Address - Street 1:110 OLSEN BLVD NE
Practice Address - Street 2:
Practice Address - City:COKATO
Practice Address - State:MN
Practice Address - Zip Code:55321-4359
Practice Address - Country:US
Practice Address - Phone:320-286-2123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-02
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY204656207Q00000X
MN54749207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00204656Medicaid
NY331880OtherFQHC NUMBER
NY00307662Medicaid
MN80021787Medicare PIN
NY00307662Medicaid