Basic Information
| Provider Information | |||||||||
| NPI: | 1346650025 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOSE | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | DAVID | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2450 RIVERSIDE AVE | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554541450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6122739824 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3900 NORTHWOODS DR | ||||||||
| Address2: | |||||||||
| City: | ARDEN HILLS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6517879600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2014 | ||||||||
| LastUpdateDate: | 08/03/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 60470 | MN | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.