Provider Demographics
NPI:1215091749
Name:KORTHALS, MARK (OD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:KORTHALS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13195 WEAVER LAKE RD
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-9410
Mailing Address - Country:US
Mailing Address - Phone:763-420-5112
Mailing Address - Fax:763-420-6957
Practice Address - Street 1:13195 WEAVER LAKE RD
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-9410
Practice Address - Country:US
Practice Address - Phone:763-420-5112
Practice Address - Fax:763-420-6957
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2015-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2972152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN151668000Medicaid
MNV01572Medicare UPIN
MN410002249Medicare ID - Type UnspecifiedOD PIN