Provider Demographics
NPI:1710274303
Name:HALLSTROM, MARK ROBERT (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ROBERT
Last Name:HALLSTROM
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2311 WAYZATA BLVD S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55405-2119
Mailing Address - Country:US
Mailing Address - Phone:612-377-5192
Mailing Address - Fax:
Practice Address - Street 1:2311 WAYZATA BLVD S
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55405-2119
Practice Address - Country:US
Practice Address - Phone:612-377-5192
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-01
Last Update Date:2011-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3233152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist