Provider Demographics
NPI:1932597002
Name:MINNESOTA DOC
Entity Type:Organization
Organization Name:MINNESOTA DOC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:PAULSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:612-390-4747
Mailing Address - Street 1:1450 ENERGY PARK DR
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55108-5274
Mailing Address - Country:US
Mailing Address - Phone:651-361-7200
Mailing Address - Fax:651-642-0223
Practice Address - Street 1:1450 ENERGY PARK DR
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55108-5274
Practice Address - Country:US
Practice Address - Phone:651-361-7200
Practice Address - Fax:651-642-0223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-24
Last Update Date:2015-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR172606-6261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service