Provider Demographics
NPI:1902919723
Name:AGRE, MARK COURTLAND (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:COURTLAND
Last Name:AGRE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4801 W 81ST ST STE 112
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55437-1111
Mailing Address - Country:US
Mailing Address - Phone:952-345-3000
Mailing Address - Fax:952-345-6789
Practice Address - Street 1:4801 W 81ST ST STE 112
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55437-1111
Practice Address - Country:US
Practice Address - Phone:952-345-3000
Practice Address - Fax:952-345-6789
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI32249-20208100000X
MN37278208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation