Provider Demographics
NPI:1487721791
Name:MIDTHUN, MARK ALAN (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ALAN
Last Name:MIDTHUN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:W6602 SCHILLING RD
Mailing Address - Street 2:UNIT C
Mailing Address - City:ONALASKA
Mailing Address - State:WI
Mailing Address - Zip Code:54650-9341
Mailing Address - Country:US
Mailing Address - Phone:608-397-5904
Mailing Address - Fax:
Practice Address - Street 1:3626 EAST AVE S STE 2A
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-7221
Practice Address - Country:US
Practice Address - Phone:608-787-6411
Practice Address - Fax:608-787-6414
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2020-03-30
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MN495712084P0800X, 2084P0800X
SD37172084P0800X
WI50549-0202084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDF66306Medicare UPIN