Basic Information
| Provider Information | |||||||||
| NPI: | 1518946292 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DUCRET | ||||||||
| FirstName: | RENE | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 166 4TH ST E | ||||||||
| Address2: | |||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551011421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512922043 | ||||||||
| FaxNumber: | 6512922204 | ||||||||
| Practice Location | |||||||||
| Address1: | 166 4TH ST E | ||||||||
| Address2: | |||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551011421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512922043 | ||||||||
| FaxNumber: | 6512922204 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2006 | ||||||||
| LastUpdateDate: | 06/09/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 30212 | MN | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 509387200 | 05 | MN | MEDICAID |