Provider Demographics
NPI:1174500888
Name:WOLVERTON, MARK (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:WOLVERTON
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 1:800 MEDICAL CENTER DR
Mailing Address - Street 2:PO BOX 800
Mailing Address - City:FAIRMONT
Mailing Address - State:MN
Mailing Address - Zip Code:56031-4575
Mailing Address - Country:US
Mailing Address - Phone:507-238-8555
Mailing Address - Fax:
Practice Address - Street 1:800 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:MN
Practice Address - Zip Code:56031-4575
Practice Address - Country:US
Practice Address - Phone:507-238-8555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN21418207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN01-12157OtherMEDICA
MNA015OtherCHAMPUS
MNHP30229OtherHEALTHPARTNERS
MN22379OtherSIOUX VALLEY
MN705219OtherARAZ
IA903294Medicaid
MN5T432WOMedicaid
MNMH9041000384OtherPREFERREDONE
MN6848OtherAVERA
MN116281Medicaid
MN5T432WOOtherBLUE CROSS
MN22379OtherSIOUX VALLEY
D49071Medicare UPIN
MN5T432WOOtherBLUE CROSS
MN80013653Medicare NSC
MN5T432WOMedicare ID - Type UnspecifiedBC MEDICARE SUPPLEMENT