Provider Demographics
NPI:1710024435
Name:SHANFELD, MARK A (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:SHANFELD
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 1:1611 ANNE ST NW
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-5114
Mailing Address - Country:US
Mailing Address - Phone:218-333-2020
Mailing Address - Fax:
Practice Address - Street 1:1611 ANNE ST NW
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-5114
Practice Address - Country:US
Practice Address - Phone:218-333-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2011-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN36199207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
0829867OtherMEDICA
ND28645OtherNDBCBS
HP57665OtherHEALTHPARTNERS
MN693363700Medicaid
1011211OtherPREFERREDONE
MN180001296Medicare PIN
MNF55303Medicare UPIN
0829867OtherMEDICA