Provider Demographics
NPI:1528374600
Name:WELLNITZ, MARK W (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:W
Last Name:WELLNITZ
Suffix:
Gender:M
Credentials:OD
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Mailing Address - Street 1:330 MONROE ST NE
Mailing Address - Street 2:APT 2
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55413-2364
Mailing Address - Country:US
Mailing Address - Phone:608-658-1571
Mailing Address - Fax:
Practice Address - Street 1:1201 GREELEY AVE N # 3
Practice Address - Street 2:
Practice Address - City:GLENCOE
Practice Address - State:MN
Practice Address - Zip Code:55336-2135
Practice Address - Country:US
Practice Address - Phone:320-864-2020
Practice Address - Fax:320-864-6678
Is Sole Proprietor?:No
Enumeration Date:2010-08-26
Last Update Date:2019-03-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN3209152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN410003453Medicare PIN