Provider Demographics
NPI:1508809930
Name:GREGERSON, MARK CONRAD (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:CONRAD
Last Name:GREGERSON
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 1:4572 COUNTY ROAD 61
Mailing Address - Street 2:
Mailing Address - City:MOOSE LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55767-9401
Mailing Address - Country:US
Mailing Address - Phone:218-485-4481
Mailing Address - Fax:
Practice Address - Street 1:4572 COUNTY ROAD 61
Practice Address - Street 2:
Practice Address - City:MOOSE LAKE
Practice Address - State:MN
Practice Address - Zip Code:55767-9401
Practice Address - Country:US
Practice Address - Phone:218-485-4481
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2019-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN29943207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN441280000Medicaid