Provider Demographics
NPI:1710166541
Name:MARK D. HOMSTAD, D.P.M., P.A.
Entity Type:Organization
Organization Name:MARK D. HOMSTAD, D.P.M., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:DENNIS
Authorized Official - Last Name:HOMSTAD
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:218-722-2008
Mailing Address - Street 1:3308 W ARROWHEAD RD
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55811-4000
Mailing Address - Country:US
Mailing Address - Phone:218-722-2008
Mailing Address - Fax:218-727-2362
Practice Address - Street 1:3308 W ARROWHEAD RD
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55811-4000
Practice Address - Country:US
Practice Address - Phone:218-722-2008
Practice Address - Fax:218-727-2362
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-29
Last Update Date:2007-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN395213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1710166541OtherNPI GROUP
MNC04106OtherGROUP LEGACY