Provider Demographics
NPI:1447019054
Name:DUNHAM, MARK LONDON II
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:LONDON
Last Name:DUNHAM
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 S LAKE ST
Mailing Address - Street 2:
Mailing Address - City:BELVIEW
Mailing Address - State:MN
Mailing Address - Zip Code:56214-4015
Mailing Address - Country:US
Mailing Address - Phone:612-685-4982
Mailing Address - Fax:
Practice Address - Street 1:207 S LAKE ST
Practice Address - Street 2:
Practice Address - City:BELVIEW
Practice Address - State:MN
Practice Address - Zip Code:56214-4015
Practice Address - Country:US
Practice Address - Phone:612-685-4982
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-18
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN374K00000X
367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No374K00000XNursing Service Related ProvidersReligious Nonmedical Practitioner