Provider Demographics
NPI:1699789719
Name:FALLEN, MARK J (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:J
Last Name:FALLEN
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:6525 FRANCE S AVE 200
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-2176
Mailing Address - Country:US
Mailing Address - Phone:952-927-6501
Mailing Address - Fax:952-653-1435
Practice Address - Street 1:6525 FRANCE AVE S
Practice Address - Street 2:SUITE 200
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-2148
Practice Address - Country:US
Practice Address - Phone:952-927-6501
Practice Address - Fax:952-653-1435
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2015-11-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN30919208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNH400108281Medicare PIN
MNF20968Medicare UPIN