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General NPI Number Information
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NPI Number | 1528374600
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Entity Type | Individual
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Provider Name | MARK W WELLNITZ O.D.
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Gender | Male
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Dates
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Enumeration Date | 08/26/2010
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Last Update Date | 03/11/2019
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Provider Practice Location Address
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Address Line | 1201 GREELEY AVE N # 3
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City | GLENCOE
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State | MN
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Zip | 55336-2135
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Country | US
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Telephone | 320-864-2020
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Fax | 320-864-6678
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Provider Business Mailing Address
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Address Line | 330 MONROE ST NE APT 2
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City | MINNEAPOLIS
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State | MN
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Zip | 55413-2364
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Country | US
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Telephone | 608-658-1571
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 3209
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License Number State | MN
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