Active NPI
Mark Robert Hallstrom, O.D.
- Optometrist
- Minneapolis, MN
National Provider Identifier
1710274303
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Optometrist
- License
- 3233
- Practice address
- 2311 Wayzata Blvd S
Minneapolis, MN 55405-2119 - Phone
- (612) 377-5192
- NPI assigned
- Jul 1, 2011
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Optometrist | 152W00000X | 3233 | MN | Primary |
Addresses
Primary practice location
2311 Wayzata Blvd S
Minneapolis, MN 55405-2119
Mailing address
2311 Wayzata Blvd S
Minneapolis, MN 55405-2119
Phone (612) 377-5192
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 3233 | MN | MD | Registered Dietitian |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1309478400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1323388800000",
"number": "1710274303",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "2311 WAYZATA BLVD S",
"city": "MINNEAPOLIS",
"state": "MN",
"postal_code": "554052119",
"telephone_number": "612-377-5192"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "2311 WAYZATA BLVD S",
"city": "MINNEAPOLIS",
"state": "MN",
"postal_code": "554052119",
"telephone_number": "612-377-5192"
}
],
"practiceLocations": [],
"basic": {
"last_name": "HALLSTROM",
"first_name": "MARK",
"middle_name": "ROBERT",
"name_prefix": "Dr.",
"credential": "O.D.",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2011-07-01",
"last_updated": "2011-12-09",
"status": "A"
},
"taxonomies": [
{
"code": "152W00000X",
"taxonomy_group": "",
"desc": "Optometrist",
"state": "MN",
"license": "3233",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Minneapolis, MN
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 9, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.