Healthcare Provider Details

I. General information

NPI: 1689670614
Provider Name (Legal Business Name): MARK GEORGE HUEFTLE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2005
Last Update Date: 08/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5225 CANYON DR
RENO NV
89519-7939
US

IV. Provider business mailing address

11995 SINGLETREE LN STE 500
EDEN PRAIRIE MN
55344-5347
US

V. Phone/Fax

Practice location:
  • Phone: 952-595-1100
  • Fax: 612-294-4903
Mailing address:
  • Phone: 952-595-1301
  • Fax: 612-294-4903

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number5643
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number5643
License Number StateNV
# 3
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number5643
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: