Active NPI
Brook Butzer Waldo, M.D.
- Psychiatry Physician
- Minneapolis, MN
National Provider Identifier
1417482308
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Psychiatry Physician
- License
- 64458
- Practice address
- 2450 Riverside Ave
F282/2a West
Minneapolis, MN 55454-1450 - Phone
- (612) 273-9824
- Fax
- (612) 273-9779
- NPI assigned
- Apr 27, 2017
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Psychiatry Physician | 2084P0800X | 64458 | MN | Primary |
Addresses
Primary practice location
2450 Riverside Ave
F282/2a West
Minneapolis, MN 55454-1450
Mailing address
2450 Riverside Ave
F282/2a West
Minneapolis, MN 55454-1450
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in MN
- Eligible to order & refer
- Part B services: No
- Medical equipment: Yes
- Home health: No
- Power mobility devices: Yes
- Hospice: No
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20181120001519 | MN | Order and Referring Only - Psychiatry | 9335493824 |
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Medicine
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1493251200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1623196800000",
"number": "1417482308",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "2450 RIVERSIDE AVE",
"address_2": "F282/2A WEST",
"city": "MINNEAPOLIS",
"state": "MN",
"postal_code": "554541450"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "2450 RIVERSIDE AVE",
"address_2": "F282/2A WEST",
"city": "MINNEAPOLIS",
"state": "MN",
"postal_code": "554541450",
"telephone_number": "612-273-9824",
"fax_number": "612-273-9779"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WALDO",
"first_name": "BROOK",
"middle_name": "BUTZER",
"credential": "M.D.",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2017-04-27",
"last_updated": "2021-06-09",
"certification_date": "2021-06-09",
"status": "A"
},
"taxonomies": [
{
"code": "2084P0800X",
"taxonomy_group": "",
"desc": "Psychiatry & Neurology, Psychiatry",
"state": "MN",
"license": "64458",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Minneapolis, MN
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 9, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.