Provider Demographics
NPI:1619967890
Name:SPANBAUER, MARK REID (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:REID
Last Name:SPANBAUER
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 1:2800 CAMPUS DR
Mailing Address - Street 2:SUITE 150
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55441-2606
Mailing Address - Country:US
Mailing Address - Phone:763-201-0492
Mailing Address - Fax:
Practice Address - Street 1:111 17TH AVE E
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308-3703
Practice Address - Country:US
Practice Address - Phone:320-762-6072
Practice Address - Fax:320-762-6145
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN23646174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN115090OtherUCARE