Basic Information
| Provider Information | |||||||||
| NPI: | 1336661644 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEIVON | ||||||||
| FirstName: | LINUS | ||||||||
| MiddleName: | MUNRENGSONG | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 EAST THIRD STREET | ||||||||
| Address2: | |||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558055047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2188287548 | ||||||||
| FaxNumber: | 3192722107 | ||||||||
| Practice Location | |||||||||
| Address1: | 1542 GOLF COURSE RD STE 204 | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557443537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2189997000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2017 | ||||||||
| LastUpdateDate: | 07/07/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD-46474 | IA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 66521 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.