Provider Demographics
NPI:1609814920
Name:MOBERG, MARK THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:THOMAS
Last Name:MOBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:109 DOCTORS PARK
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303
Mailing Address - Country:US
Mailing Address - Phone:320-253-3637
Mailing Address - Fax:320-253-5412
Practice Address - Street 1:109 DOCTORS PARK
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303
Practice Address - Country:US
Practice Address - Phone:320-253-3637
Practice Address - Fax:320-253-5412
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2012-08-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN20295207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
D48825Medicare UPIN