Basic Information
| Provider Information | |||||||||
| NPI: | 1922090034 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SOCKALOSKY | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2910 CENTRE POINTE DR | ||||||||
| Address2: | 35-121A, CHILDRENS HEALTH CARE | ||||||||
| City: | ROSEVILLE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551131182 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6518552327 | ||||||||
| FaxNumber: | 6518552310 | ||||||||
| Practice Location | |||||||||
| Address1: | 347 SMITH AVE N | ||||||||
| Address2: | CHILDRENS SPECIALTY CLINIC-DIABETES/ENDOCRINOLOGY-STPL | ||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551022387 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512206818 | ||||||||
| FaxNumber: | 6512206064 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2005 | ||||||||
| LastUpdateDate: | 09/06/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0205X | 21201 | MN | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Endocrinology |
ID Information
| ID | Type | State | Issuer | Description | 126700100 | 05 | MN | MEDICAID |