Basic Information
| Provider Information | |||||||||
| NPI: | 1659698512 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOLDEN | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | DANIEL | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2854 HIGHWAY 55 STE 130 | ||||||||
| Address2: | |||||||||
| City: | EAGAN | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551211447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6518423349 | ||||||||
| FaxNumber: | 6518423391 | ||||||||
| Practice Location | |||||||||
| Address1: | 6440 NICOLLET AVE | ||||||||
| Address2: | |||||||||
| City: | RICHFIELD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554231697 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6128611622 | ||||||||
| FaxNumber: | 6128612307 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2010 | ||||||||
| LastUpdateDate: | 02/05/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 256931 | MA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 54115 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 54115 | 01 | MN | MN MEDICAL LICENSE | OTHER |