Provider Demographics
NPI:1427169812
Name:WHEATON, MARK TODD (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:TODD
Last Name:WHEATON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21920 MINNETONKA BLVD
Mailing Address - Street 2:
Mailing Address - City:EXCELSIOR
Mailing Address - State:MN
Mailing Address - Zip Code:55331-8615
Mailing Address - Country:US
Mailing Address - Phone:952-593-0500
Mailing Address - Fax:952-593-4005
Practice Address - Street 1:21920 MINNETONKA BLVD
Practice Address - Street 2:
Practice Address - City:EXCELSIOR
Practice Address - State:MN
Practice Address - Zip Code:55331-8615
Practice Address - Country:US
Practice Address - Phone:952-593-0500
Practice Address - Fax:952-593-4005
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN32449208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
F49467Medicare UPIN
MN5198160Medicare ID - Type Unspecified