Provider Demographics
NPI:1699713883
Name:OLMSTED, MARK DUANE (OD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:DUANE
Last Name:OLMSTED
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 1:117 E LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:FERGUS FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56537-2216
Mailing Address - Country:US
Mailing Address - Phone:218-736-7555
Mailing Address - Fax:218-739-6586
Practice Address - Street 1:117 E LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:FERGUS FALLS
Practice Address - State:MN
Practice Address - Zip Code:56537-2216
Practice Address - Country:US
Practice Address - Phone:218-736-7555
Practice Address - Fax:218-739-6586
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2099152W00000X
WI2141152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN47845OLOtherBLUE CROSS BLUE SHIELD
MN410049146OtherRAILROAD MEDICARE
MN1010283OtherPREFERRED ONE
MN2200947OtherMEDICA
ND60615Medicaid
MN119523900Medicaid
MN119523900Medicaid
MN410000843Medicare ID - Type Unspecified
ND60615Medicaid