Provider Demographics
NPI:1225011141
Name:KRASEMANN, MARK ALAN (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALAN
Last Name:KRASEMANN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:8003 E APACHE TRL
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85207-8503
Mailing Address - Country:US
Mailing Address - Phone:480-986-1601
Mailing Address - Fax:480-986-9242
Practice Address - Street 1:8003 E APACHE TRL
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85207-8503
Practice Address - Country:US
Practice Address - Phone:480-986-1601
Practice Address - Fax:480-986-9242
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-23
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ841152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZU38114Medicare UPIN