Provider Demographics
NPI:1447234554
Name:KIDMAN, MARK A (OD)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:A
Last Name:KIDMAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3630 11TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55901-4276
Mailing Address - Country:US
Mailing Address - Phone:507-288-2457
Mailing Address - Fax:507-288-1299
Practice Address - Street 1:3630 11TH AVE NW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55901-4276
Practice Address - Country:US
Practice Address - Phone:507-288-2457
Practice Address - Fax:507-288-1299
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2009-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2742152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
2201279OtherMEDIEA CHOICE SELECT
MN03S15KIOtherBCBS OF MN
1024471OtherPREFERRED ONE
MN743070100Medicaid
HP44092OtherHEALTHPARTNERS
MN410001296Medicare ID - Type Unspecified
2201279OtherMEDIEA CHOICE SELECT
MN743070100Medicaid