Provider Demographics
NPI:1003812991
Name:BREWER, MARK EUGENE (DC)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:EUGENE
Last Name:BREWER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3800 SHORELINE DR
Mailing Address - Street 2:
Mailing Address - City:WAYZATA
Mailing Address - State:MN
Mailing Address - Zip Code:55391-9785
Mailing Address - Country:US
Mailing Address - Phone:952-471-2555
Mailing Address - Fax:952-471-2556
Practice Address - Street 1:3800 SHORELINE DR
Practice Address - Street 2:
Practice Address - City:WAYZATA
Practice Address - State:MN
Practice Address - Zip Code:55391-9785
Practice Address - Country:US
Practice Address - Phone:952-471-2555
Practice Address - Fax:952-471-2556
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-24
Last Update Date:2011-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2026111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN204228200Medicaid
MN204228200Medicaid
MNT60584Medicare UPIN