Provider Demographics
NPI:1982612610
Name:WOLTERS, MARK A
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:WOLTERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 S 8TH ST
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404-1208
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:825 S 8TH ST
Practice Address - Street 2:PPC 206
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-1208
Practice Address - Country:US
Practice Address - Phone:612-347-5321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN39895207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G51734Medicare UPIN