Basic Information
Provider Information | |||||||||
NPI: | 1346324506 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PERDUE | ||||||||
FirstName: | DAVID | ||||||||
MiddleName: | GARETT | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 14909 | ||||||||
Address2: |   | ||||||||
City: | MINNEAPOLIS | ||||||||
State: | MN | ||||||||
PostalCode: | 554140909 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6128711145 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2550 UNIVERSITY AVE W | ||||||||
Address2: | SUITE 423 SOUTH | ||||||||
City: | SAINT PAUL | ||||||||
State: | MN | ||||||||
PostalCode: | 551141052 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6128711145 | ||||||||
FaxNumber: | 6128705491 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/24/2006 | ||||||||
LastUpdateDate: | 12/04/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 43435 | MN | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
ID | Type | State | Issuer | Description | 0596858 | 05 | IA |   | MEDICAID | HP56030 | 01 | MN | HEALTH PARTNERS | OTHER | 812915100 | 05 | MN |   | MEDICAID | 135330 | 01 | MN | UCARE | OTHER | 29-00430 | 01 | MN | MEDICA CHOICE | OTHER | 34706700 | 05 | WI |   | MEDICAID | B664 | 01 | MN | CHAMPUS | OTHER | 1612851 | 01 | MN | ARAZ | OTHER | 0148053 | 05 | MT |   | MEDICAID | 29-00011 | 01 | MN | MEDICA PRIMARY | OTHER |