Provider Demographics
NPI:1306800107
Name:HAYCRAFT SCHMOTTER, KIMBERLY J (MD)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:J
Last Name:HAYCRAFT SCHMOTTER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:J
Other - Last Name:HAYCRAFT SCHMOTTER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:24004 W SUNSET ISLAND DR
Mailing Address - Street 2:
Mailing Address - City:COHASSET
Mailing Address - State:MN
Mailing Address - Zip Code:55721-2130
Mailing Address - Country:US
Mailing Address - Phone:612-516-2868
Mailing Address - Fax:
Practice Address - Street 1:701 DELLWOOD ST S
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MN
Practice Address - Zip Code:55008-1920
Practice Address - Country:US
Practice Address - Phone:763-689-7700
Practice Address - Fax:763-689-7941
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2024-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN39788207Q00000X
WI63359207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNFH5009887OtherDEA
MN447516000Medicaid
G52932Medicare UPIN