Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | 125.053428 | IL |
NPI | 1003075383 |
---|---|
Provider Name | David Jewison |
First Address | Minneapolis, MN 55414-2924 |
Second Address | Minneapolis, MN 55414-3205 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/06/2008 |
Last Update Date | 30/01/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
107369 | MINNESOTA MEDICAL LICENSE NUMBER (01) | MN |