Provider Demographics
NPI:1043289580
Name:HOMSTAD, MARK DENNIS (DPM)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:DENNIS
Last Name:HOMSTAD
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6625 LYNDALE AVE S STE 30
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55423-2373
Mailing Address - Country:US
Mailing Address - Phone:612-788-8778
Mailing Address - Fax:866-691-8423
Practice Address - Street 1:6625 LYNDALE AVE S STE 105
Practice Address - Street 2:
Practice Address - City:RICHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55423-2673
Practice Address - Country:US
Practice Address - Phone:612-788-8778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN395213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN86682HOOtherBLUE CROSS/ BLUE SHIELD
MN2700556OtherMEDICA
MN473525100Medicaid
MN86682HOOtherBLUE CROSS/ BLUE SHIELD
MNT39316Medicare UPIN
MN4800-00548Medicare PIN