Provider Demographics
NPI:1902821937
Name:MOE, MARK JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:JOHN
Last Name:MOE
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 1:811 2ND ST. SE
Mailing Address - Street 2:SUITE A
Mailing Address - City:LITTLE FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56345
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:811 2ND ST SE STE A
Practice Address - Street 2:
Practice Address - City:LITTLE FALLS
Practice Address - State:MN
Practice Address - Zip Code:56345-3505
Practice Address - Country:US
Practice Address - Phone:320-631-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2012-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN46385207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN779460600Medicaid
MN879S1MOOtherBCBS OF MINNESOTA
MN132024C736OtherUCARE MINNESOTA
2145399OtherAMERICA'S PPO
0406746OtherMEDICA
HP43143OtherHEALTH PARTNERS
NA9231041286OtherPREFERRED ONE
MNA031OtherTRICARE
MN132024C736OtherUCARE MINNESOTA
P00154233Medicare ID - Type UnspecifiedRR MEDICARE
MN779460600Medicaid