Provider Demographics
NPI:1528050119
Name:EAGAN VALLEY PEDIATRICS, P.A.
Entity type:Organization
Organization Name:EAGAN VALLEY PEDIATRICS, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:E
Authorized Official - Last Name:DUFORT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:952-432-4373
Mailing Address - Street 1:14135 CEDAR AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:APPLE VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55124-4522
Mailing Address - Country:US
Mailing Address - Phone:952-432-4373
Mailing Address - Fax:952-997-5679
Practice Address - Street 1:14135 CEDAR AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:APPLE VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55124-4522
Practice Address - Country:US
Practice Address - Phone:952-432-4373
Practice Address - Fax:952-997-5679
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center