MEDICARE: DR. MARK GEORGE HUEFTLE M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085N0700X	Neuroradiology Physician	5643	NV
2	2085R0202X	Diagnostic Radiology Physician	5643	NV
3	2085R0204X	Vascular & Interventional Radiology Physician	5643	NV

General Provider Information

NPI Number	:	1689670614
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK GEORGE HUEFTLE M.D.

Provider Business Mailing Address
First Line	:	11995 SINGLETREE LN
Second Line	:	STE 500
City	:	EDEN PRAIRIE
State	:	MN
Zip	:	55344-5347
Country	:	US
Telephone Number	:	952-595-1301
Fax Number	:	612-294-4903

Provider Business Practice Location Address
First Line	:	5225 CANYON DR
Second Line	:
City	:	RENO
State	:	NV
Zip	:	89519-7939
Country	:	US
Telephone Number	:	952-595-1100
Fax Number	:	612-294-4903

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/23/2005
Last Update Date	:	08/16/2013

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