Provider Demographics
NPI:1902919723
Name:AGRE, MARK COURTLAND (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:COURTLAND
Last Name:AGRE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 UNIVERSITY AVE W
Mailing Address - Street 2:SUITE 10
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-3898
Mailing Address - Country:US
Mailing Address - Phone:651-999-1050
Mailing Address - Fax:
Practice Address - Street 1:1600 UNIVERSITY AVE W
Practice Address - Street 2:SUITE 10
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-3898
Practice Address - Country:US
Practice Address - Phone:651-999-1050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN37278208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation