Provider Demographics
NPI:1093787459
Name:HARDER, MARK HENRY (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:HENRY
Last Name:HARDER
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 1:501 E ORANGEBURG AVE STE B
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-5578
Mailing Address - Country:US
Mailing Address - Phone:209-596-4360
Mailing Address - Fax:209-566-0685
Practice Address - Street 1:501 E ORANGEBURG AVE STE B
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350
Practice Address - Country:US
Practice Address - Phone:209-596-4360
Practice Address - Fax:209-566-0685
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-01
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA07481T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0074810Medicaid
CA1093787459Medicaid
CA1093787459Medicaid
CASD0074811Medicare ID - Type UnspecifiedNHIC MEDICARE PROVIDER
CA0549610003Medicare NSC