Basic Information
| Provider Information | |||||||||
| NPI: | 1962610956 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BHOOPAL | ||||||||
| FirstName: | JAIDEV | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 E 3RD ST | ||||||||
| Address2: | ESSENTIA HEALTH DULUTH CLINIC | ||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558051951 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187868364 | ||||||||
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| Practice Location | |||||||||
| Address1: | 400 E 3RD ST | ||||||||
| Address2: | ESSENTIA HEALTH DULUTH CLINIC | ||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187868364 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2007 | ||||||||
| LastUpdateDate: | 08/06/2018 | ||||||||
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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 | 207R00000X | N0648 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 55855 | MN | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 55855 | MN | N | Allopathic & Osteopathic Physicians | Hospitalist | 207RC0200X | 55855 | MN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1962610956 | 05 | WI | MEDICAID | 0004-0018721 | 01 | MN | MEDICA | OTHER | 1962610956 | 05 | MN | MEDICAID | 1975229-01 | 05 | TX | MEDICAID |