MEDICARE: DR. MARK ROBERT HALLSTROM O.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	152W00000X	Optometrist	3233	MN

General Provider Information

NPI Number	:	1710274303
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK ROBERT HALLSTROM O.D.

Provider Business Mailing Address
First Line	:	2311 WAYZATA BLVD S
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55405-2119
Country	:	US
Telephone Number	:	612-377-5192
Fax Number	:

Provider Business Practice Location Address
First Line	:	2311 WAYZATA BLVD S
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55405-2119
Country	:	US
Telephone Number	:	612-377-5192
Fax Number	:

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

Provider Enumeration Date	:	07/01/2011
Last Update Date	:	12/09/2011

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