Provider Demographics
NPI:1154313963
Name:WALDMIRE, MARK WILLIAM
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:WILLIAM
Last Name:WALDMIRE
Suffix:
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 1:4633 WHITNEY AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95821-4100
Mailing Address - Country:US
Mailing Address - Phone:916-487-1717
Mailing Address - Fax:
Practice Address - Street 1:4633 WHITNEY AVE
Practice Address - Street 2:SUITE A
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95821-4100
Practice Address - Country:US
Practice Address - Phone:916-487-1717
Practice Address - Fax:916-487-3081
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-17
Last Update Date:2015-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10098T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0100980Medicaid
CAFW154AMedicare PIN
CASD0100980Medicare PIN
FW161ZMedicare PIN
CA3939210001Medicare NSC
CASD0100980Medicaid