Provider Demographics
NPI:1215997952
Name:SODERBERG, DOUGLAS MARK (MD)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:MARK
Last Name:SODERBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:DOUGLAS
Other - Middle Name:MARK
Other - Last Name:SODERBERG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:5415 QUEEN AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55410-2530
Mailing Address - Country:US
Mailing Address - Phone:612-963-1367
Mailing Address - Fax:612-677-3324
Practice Address - Street 1:5415 QUEEN AVE S
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55410-2530
Practice Address - Country:US
Practice Address - Phone:612-963-1367
Practice Address - Fax:612-677-3324
Is Sole Proprietor?:No
Enumeration Date:2006-03-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN26672207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNA95532Medicare UPIN