Provider Demographics
NPI:1588749642
Name:KJOME, DONALD WAYNE (MD)
Entity type:Individual
Prefix:
First Name:DONALD
Middle Name:WAYNE
Last Name:KJOME
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:967 LAKE ST S
Mailing Address - Street 2:
Mailing Address - City:FOREST LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55025-2616
Mailing Address - Country:US
Mailing Address - Phone:651-464-1113
Mailing Address - Fax:651-464-0853
Practice Address - Street 1:967 LAKE ST S
Practice Address - Street 2:
Practice Address - City:FOREST LAKE
Practice Address - State:MN
Practice Address - Zip Code:55025-2616
Practice Address - Country:US
Practice Address - Phone:651-464-1113
Practice Address - Fax:651-464-0853
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN22028207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN195588800Medicaid
MN195588800Medicaid
MNA95470Medicare UPIN