NPIMap

Organization Active NPI

Mark S Mellstrom MD PA

  • Primary Care Clinic/Center
  • Lakeville, MN
National Provider Identifier
1629244686
Registry record updated Apr 30, 2008
On this page

Key facts

NPPES NPI Registry
Primary specialty
Primary Care Clinic/CenterTaxonomy code 261QP2300X
License
6208286 Issued in MN
Legal business name
MARK S MELLSTROM MD PA
Practice address
20157 Icenic Trail
Lakeville, MN 55044
Phone
(952) 469-3393
Fax
(952) 469-3399
NPI assigned
Apr 30, 2008
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 30, 2008

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Mark S. Mellstrom, M.D.NPI 1346302106
Title
Owner
Phone
(952) 469-3393

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Primary Care Clinic/Center 261QP2300X 6208286 MN Primary

Addresses

Primary practice location

20157 Icenic Trail
Lakeville, MN 55044

Mailing address

20157 Icenic Trail
Lakeville, MN 55044
Phone (952) 469-3393

Other names 1

  • Lakeville Family Practice Doing business as

National Provider Directory

National Provider Directory

Locations

20157 Icenic Trl
Lakeville, MN 55044
Phone (952) 469-3393

Practitioners & affiliated clinicians

Practitioners 4

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1209513600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1209513600000",
    "number": "1629244686",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "20157 ICENIC TRAIL",
            "city": "LAKEVILLE",
            "state": "MN",
            "postal_code": "55044",
            "telephone_number": "952-469-3393",
            "fax_number": "952-469-3399"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "20157 ICENIC TRAIL",
            "city": "LAKEVILLE",
            "state": "MN",
            "postal_code": "55044",
            "telephone_number": "952-469-3393",
            "fax_number": "952-469-3399"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MARK S MELLSTROM MD PA",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-04-30",
        "last_updated": "2008-04-30",
        "status": "A",
        "authorized_official_last_name": "MELLSTROM",
        "authorized_official_first_name": "MARK",
        "authorized_official_middle_name": "S.",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "952-469-3393",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "261QP2300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Primary Care",
            "state": "MN",
            "license": "6208286",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Lakeville Family Practice",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Lakeville, MN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 30, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.