Provider Demographics
NPI:1740451525
Name:SMITH, MARK EDWARD (DO)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:EDWARD
Last Name:SMITH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:PO BOX 14909
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55414-0909
Mailing Address - Country:US
Mailing Address - Phone:612-871-1145
Mailing Address - Fax:612-870-5491
Practice Address - Street 1:237 RADIO DR STE 210
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-4478
Practice Address - Country:US
Practice Address - Phone:612-871-1145
Practice Address - Fax:612-870-5491
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-19
Last Update Date:2018-10-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NE512207R00000X
MN63619207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine