Provider Demographics
NPI:1932174422
Name:STOLTENBERG, JOHN J (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:J
Last Name:STOLTENBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 OSBORNE RD NE
Mailing Address - Street 2:
Mailing Address - City:FRIDLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55432-2767
Mailing Address - Country:US
Mailing Address - Phone:952-843-4333
Mailing Address - Fax:952-843-4301
Practice Address - Street 1:500 OSBORNE RD NE
Practice Address - Street 2:
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432-2765
Practice Address - Country:US
Practice Address - Phone:952-843-4333
Practice Address - Fax:952-843-4301
Is Sole Proprietor?:No
Enumeration Date:2006-02-20
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN21002174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN845593700Medicaid
MNA94157Medicare UPIN
MN845593700Medicaid