Provider Demographics
NPI:1316471386
Name:KRAFT, ETHAN TERRY (MD)
Entity type:Individual
Prefix:DR
First Name:ETHAN
Middle Name:TERRY
Last Name:KRAFT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:13359 ISLE DR
Mailing Address - Street 2:STE 1
Mailing Address - City:BAXTER
Mailing Address - State:MN
Mailing Address - Zip Code:56425-2223
Mailing Address - Country:US
Mailing Address - Phone:218-454-3077
Mailing Address - Fax:888-835-7231
Practice Address - Street 1:13359 ISLE DR
Practice Address - Street 2:STE 1
Practice Address - City:BAXTER
Practice Address - State:MN
Practice Address - Zip Code:56425-2223
Practice Address - Country:US
Practice Address - Phone:218-454-3077
Practice Address - Fax:888-835-7231
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-17
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MN71666207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty