Provider Demographics
NPI:1922144468
Name:ANDRE, MARK ELLIOT (OD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ELLIOT
Last Name:ANDRE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:MARK
Other - Middle Name:E
Other - Last Name:ANDRE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:221 MAIN STREET NORTH
Mailing Address - Street 2:P.O. BOX 261
Mailing Address - City:CROSBY
Mailing Address - State:ND
Mailing Address - Zip Code:58730-0261
Mailing Address - Country:US
Mailing Address - Phone:701-965-6590
Mailing Address - Fax:701-965-6591
Practice Address - Street 1:221 MAIN STREET NORTH
Practice Address - Street 2:
Practice Address - City:CROSBY
Practice Address - State:ND
Practice Address - Zip Code:58730-0261
Practice Address - Country:US
Practice Address - Phone:701-965-6590
Practice Address - Fax:701-965-6591
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND374152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND060266Medicaid
MT0482069Medicaid
ND060229Medicaid
MT0482069Medicaid
ND060229Medicaid
ND0714280002Medicare NSC
ND8923Medicare PIN
ND0714280001Medicare NSC
ND060266Medicaid