Provider Demographics
NPI:1215980008
Name:KNUDSON, DEAN K (MD)
Entity type:Individual
Prefix:
First Name:DEAN
Middle Name:K
Last Name:KNUDSON
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 1:1155 FORD ROAD
Mailing Address - Street 2:UNIT B
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55426
Mailing Address - Country:US
Mailing Address - Phone:952-378-1800
Mailing Address - Fax:952-378-1714
Practice Address - Street 1:1155 FORD ROAD
Practice Address - Street 2:UNIT B
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55426
Practice Address - Country:US
Practice Address - Phone:952-378-1800
Practice Address - Fax:952-378-1714
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-19
Last Update Date:2014-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN319282084P0800X
MN0319282084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN477288100Medicaid
MN260002843Medicare Oscar/Certification
C36242Medicare UPIN
260000147Medicare ID - Type Unspecified