Basic Information
Provider Information | |||||||||
NPI: | 1952363749 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DEAL | ||||||||
FirstName: | LAWRENCE | ||||||||
MiddleName: | DAVID | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6401 UNIVERSITY AVE NE | ||||||||
Address2: |   | ||||||||
City: | FRIDLEY | ||||||||
State: | MN | ||||||||
PostalCode: | 554324341 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7635725710 | ||||||||
FaxNumber: | 7635713008 | ||||||||
Practice Location | |||||||||
Address1: | 4000 CENTRAL AVE NE | ||||||||
Address2: |   | ||||||||
City: | COLUMBIA HEIGHTS | ||||||||
State: | MN | ||||||||
PostalCode: | 554212968 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7635725710 | ||||||||
FaxNumber: | 7637828100 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/05/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | X | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 38800 | MN | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 112840 | 01 | MN | UCARE MN | OTHER | 772045 | 01 | MN | AMERICA'S PPO | OTHER | 5206617 | 01 | MN | AETNA | OTHER | 08F14DE | 01 | MN | BCBS OF MN | OTHER | HP26068 | 01 | MN | HEALTHPARTNERS | OTHER | 1016404 | 01 | MN | PREFERRED ONE | OTHER | 0102809 | 01 | MN | MEDICA | OTHER | 6603825 | 01 | MN | MEDICA UC | OTHER |