Provider Demographics
NPI:1285898767
Name:EWALD, JEFFREY ALLEN (DC)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:ALLEN
Last Name:EWALD
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2501 W 84TH ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55431-1602
Mailing Address - Country:US
Mailing Address - Phone:952-888-4777
Mailing Address - Fax:
Practice Address - Street 1:2501 W 84TH ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55431-1602
Practice Address - Country:US
Practice Address - Phone:952-888-4777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-15
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1742111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN812727100Medicaid
MN812727100Medicaid
MN350001881Medicare Oscar/Certification