Provider Demographics
NPI:1033101845
Name:JEPPESEN, MARK H (OD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:H
Last Name:JEPPESEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 B 3RD AVE NW
Mailing Address - Street 2:
Mailing Address - City:WAVERLY
Mailing Address - State:IA
Mailing Address - Zip Code:50677
Mailing Address - Country:US
Mailing Address - Phone:319-352-3490
Mailing Address - Fax:319-352-0468
Practice Address - Street 1:2020 3RD AVE NW
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:IA
Practice Address - Zip Code:50677-2065
Practice Address - Country:US
Practice Address - Phone:319-352-3490
Practice Address - Fax:319-352-0468
Is Sole Proprietor?:No
Enumeration Date:2005-08-17
Last Update Date:2015-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02199152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1245969Medicaid
IAI10149Medicare PIN
IA1245969Medicaid
IAU89981Medicare UPIN