Marson Rubianto Eka Putra, MD, PHD

Primary specialty

Student in an Organized Health Care Education/Training ProgramTaxonomy code 390200000X

Practice address

420 Delaware St SE
Minneapolis, MN 55455-0341

Phone

(612) 625-1969

Fax

(612) 625-7950

NPI assigned

Apr 29, 2025

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in MN

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine, Doctor of Philosophy

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1745884800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1745884800000",
    "number": "1659169704",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "420 DELAWARE ST SE",
            "address_2": "MMC 295",
            "city": "MINNEAPOLIS",
            "state": "MN",
            "postal_code": "55455",
            "telephone_number": "612-625-1969",
            "fax_number": "612-625-7950"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "420 DELAWARE ST SE",
            "city": "MINNEAPOLIS",
            "state": "MN",
            "postal_code": "554550341",
            "telephone_number": "612-625-1969",
            "fax_number": "612-625-7950"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "PUTRA",
        "first_name": "MARSON",
        "middle_name": "RUBIANTO EKA",
        "credential": "MD, PHD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2025-04-29",
        "last_updated": "2025-04-29",
        "certification_date": "2025-04-20",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "390200000X",
            "taxonomy_group": "",
            "desc": "Student in an Organized Health Care Education/Training Program",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Candela Puscar, M.D.
• Jessica Magarite Pusch, LPCC, LADC
• Michael Alexander Puskarich, MD
• Pamela Raja Puthoor, MD
• Matthew D Putnam, MD
• Adam M Putschoegl, DO
• Stephany Putz
• Alyssa Ann Pyburn, PA-C
• Mary E Pylipow, M.D.
• Mia Pylkkanen

• Student in an Organized Health Care Education/Training Program in Minneapolis, MN
• Providers in Minneapolis, MN by specialty
• Student in an Organized Health Care Education/Training Program in Minnesota

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 29, 2025; 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.

Verify at the official NPI Registry.