Provider Demographics
NPI:1174732952
Name:BOCKHOLD, STEPHEN M (MD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:M
Last Name:BOCKHOLD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 SKYLINE BLVD STE 1
Mailing Address - Street 2:
Mailing Address - City:CLOQUET
Mailing Address - State:MN
Mailing Address - Zip Code:55720-1199
Mailing Address - Country:US
Mailing Address - Phone:218-879-4641
Mailing Address - Fax:
Practice Address - Street 1:512 SKYLINE BLVD STE 1
Practice Address - Street 2:
Practice Address - City:CLOQUET
Practice Address - State:MN
Practice Address - Zip Code:55720-1199
Practice Address - Country:US
Practice Address - Phone:218-879-4641
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2023-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN49675207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN16P73BOOtherBCBS
P00436607OtherRRMEDICARE PTAN
MN857913100Medicaid
1174732952OtherMEDICA
MN16P73BOOtherBCBS