Provider Demographics
NPI:1548221724
Name:AHLQUIST, MARK DAVID (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:DAVID
Last Name:AHLQUIST
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 HEALTHY WAY
Mailing Address - Street 2:
Mailing Address - City:OLIVIA
Mailing Address - State:MN
Mailing Address - Zip Code:56277-1117
Mailing Address - Country:US
Mailing Address - Phone:320-523-1261
Mailing Address - Fax:320-523-8349
Practice Address - Street 1:420 MAIN STREET N
Practice Address - Street 2:
Practice Address - City:RENVILLE
Practice Address - State:MN
Practice Address - Zip Code:56284-0606
Practice Address - Country:US
Practice Address - Phone:320-329-8395
Practice Address - Fax:320-329-8397
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2018-11-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN32093207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MND48355Medicare UPIN