Provider Demographics
NPI:1538143516
Name:NORMAN, MARK LEWIS III (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:LEWIS
Last Name:NORMAN
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:6533 DREW AVE S
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-2103
Mailing Address - Country:US
Mailing Address - Phone:952-927-7138
Mailing Address - Fax:952-924-4021
Practice Address - Street 1:6533 DREW AVE S
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-2103
Practice Address - Country:US
Practice Address - Phone:952-927-7138
Practice Address - Fax:952-924-4021
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-02
Last Update Date:2011-10-24
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MN25882207W00000X
WI26691020207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN439875100Medicaid
MN180000977Medicare ID - Type Unspecified
MN439875100Medicaid