Provider Demographics
NPI:1124124623
Name:MOEN, MARK A (OD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:MOEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 130
Mailing Address - Street 2:
Mailing Address - City:DEVILS LAKE
Mailing Address - State:ND
Mailing Address - Zip Code:58301-0130
Mailing Address - Country:US
Mailing Address - Phone:701-662-4085
Mailing Address - Fax:701-662-6685
Practice Address - Street 1:404 HWY 2 EAST
Practice Address - Street 2:
Practice Address - City:DEVILS LAKE
Practice Address - State:ND
Practice Address - Zip Code:58301-0130
Practice Address - Country:US
Practice Address - Phone:701-662-4085
Practice Address - Fax:701-662-6685
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND441152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND450433379000OtherWORKERS SAFETY AND COMP
ND800441OtherND VISION SERVICES
ND8844OtherBS OF NORTH DAKOTA
NDCI2649OtherPALMETTO GBA - RAILROAD MEDICARE
ND0311120001OtherCIGNA MEDICARE SERVICE
ND60342Medicaid
ND8844OtherBS OF NORTH DAKOTA
ND450433379000OtherWORKERS SAFETY AND COMP