Provider Demographics
NPI:1194742767
Name:AUTREY, ALLEN W (MD)
Entity type:Individual
Prefix:
First Name:ALLEN
Middle Name:W
Last Name:AUTREY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4222 OAKMEDE LN
Mailing Address - Street 2:
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-7609
Mailing Address - Country:US
Mailing Address - Phone:651-398-8644
Mailing Address - Fax:
Practice Address - Street 1:69 EXCHANGE ST W
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-1004
Practice Address - Country:US
Practice Address - Phone:651-232-3348
Practice Address - Fax:651-232-3539
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN27794207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNA95670Medicare UPIN