Provider Demographics
NPI:1487601316
Name:MUTNICK, JACK LEON-MAX (MD)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:LEON-MAX
Last Name:MUTNICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:3440 MOLINA ST
Mailing Address - Street 2:
Mailing Address - City:SHAKOPEE
Mailing Address - State:MN
Mailing Address - Zip Code:55379-5444
Mailing Address - Country:US
Mailing Address - Phone:714-296-6777
Mailing Address - Fax:800-785-5608
Practice Address - Street 1:3939 W 69TH ST STE A
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-2001
Practice Address - Country:US
Practice Address - Phone:612-930-8462
Practice Address - Fax:800-785-5608
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN48180207K00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology