Provider Demographics
NPI:1346302106
Name:MELLSTROM, MARK STANLEY (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:STANLEY
Last Name:MELLSTROM
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 1:200 1ST ST SW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55905-0001
Mailing Address - Country:US
Mailing Address - Phone:651-267-5000
Mailing Address - Fax:
Practice Address - Street 1:701 HEWITT BLVD
Practice Address - Street 2:
Practice Address - City:RED WING
Practice Address - State:MN
Practice Address - Zip Code:55066-2848
Practice Address - Country:US
Practice Address - Phone:651-267-5000
Practice Address - Fax:651-267-5964
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN27926207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN472435600Medicaid
MNP00055701OtherRAILROAD MEDICARE
MN28475EMOtherBCBS GROUP #
MN08S62MEOtherBCBS INDIV #
MN129840OtherUCARE
MN0103164OtherMEDICA ID
MN129840OtherUCARE