Provider Demographics
NPI:1346212495
Name:SIMON, GWENDOLYN BLECHERT (MD)
Entity type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:BLECHERT
Last Name:SIMON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8170 33RD AVE S
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8450 SEASONS PKWY
Practice Address - Street 2:MAIL STOP 32900A
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-4402
Practice Address - Country:US
Practice Address - Phone:651-702-5300
Practice Address - Fax:651-702-5305
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN43448207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN938166000Medicaid
110009152Medicare ID - Type Unspecified
H86901Medicare UPIN