Provider Demographics
NPI:1215934559
Name:HENNEN, MARK (OD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:HENNEN
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 1:1613 ATWATER PATH
Mailing Address - Street 2:
Mailing Address - City:INVER GROVE HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55077-1201
Mailing Address - Country:US
Mailing Address - Phone:651-455-6631
Mailing Address - Fax:
Practice Address - Street 1:1540 HUMBOLDT AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55118-3417
Practice Address - Country:US
Practice Address - Phone:651-457-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2010-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1944152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN237223100Medicaid
MN410001239Medicare ID - Type Unspecified
MN237223100Medicaid