Provider Demographics
NPI:1992795504
Name:FJELSTAD, KIM DARYL (DPM)
Entity type:Individual
Prefix:DR
First Name:KIM
Middle Name:DARYL
Last Name:FJELSTAD
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:14000 NICOLLET AVE
Mailing Address - Street 2:SUITE 306
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-5790
Mailing Address - Country:US
Mailing Address - Phone:952-435-2629
Mailing Address - Fax:952-435-2650
Practice Address - Street 1:14000 NICOLLET AVE
Practice Address - Street 2:SUITE 306
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-5790
Practice Address - Country:US
Practice Address - Phone:952-435-2629
Practice Address - Fax:952-435-2650
Is Sole Proprietor?:No
Enumeration Date:2005-10-25
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN410213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN913525100Medicaid
MN913525100Medicaid
MN480000641Medicare PIN
T39518Medicare UPIN
MN913525100Medicaid