Provider Demographics
NPI:1144333667
Name:CHEESEBRO, JOHN WILLIAM (DPM)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:WILLIAM
Last Name:CHEESEBRO
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 1:6625 LYNDALE AVE S STE 300
Mailing Address - Street 2:
Mailing Address - City:RICHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55423-2491
Mailing Address - Country:US
Mailing Address - Phone:612-788-8778
Mailing Address - Fax:612-869-3473
Practice Address - Street 1:2805 CAMPUS DR STE 225
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55441-2678
Practice Address - Country:US
Practice Address - Phone:612-788-8778
Practice Address - Fax:612-869-3473
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN366213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN0541840001OtherADMINISTAR DEFENSE ID
MN323225500Medicaid
MN271055OtherMEDICA PROVIDER ID
MNHP13053OtherHEALTHPARTNERS PROVIDER #
MI11691MIOtherBC/BS PROVIDER ID
MN411695192OtherFEDERAL TAX ID