Healthcare Provider Details

I. General information

NPI: 1710340724
Provider Name (Legal Business Name): MARK KENNETH MAGNUS DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2016
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 CEDARDALE DR SE
OWATONNA MN
55060-4425
US

IV. Provider business mailing address

225 CEDARDALE DR SE
OWATONNA MN
55060-4425
US

V. Phone/Fax

Practice location:
  • Phone: 507-288-3443
  • Fax:
Mailing address:
  • Phone: 507-288-3443
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number1169
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number1138
License Number StateWI
# 4
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number1138
License Number StateWI
# 5
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number016005815
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: