Provider Demographics
NPI:1376983874
Name:OBENCHAIN, MARK ALLEN (OD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ALLEN
Last Name:OBENCHAIN
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 1:15933 CLAYTON RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63011-2172
Mailing Address - Country:US
Mailing Address - Phone:636-200-4393
Mailing Address - Fax:636-527-0838
Practice Address - Street 1:5101 N. DAVIS HWY
Practice Address - Street 2:SUITE A
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32503-2040
Practice Address - Country:US
Practice Address - Phone:850-479-7379
Practice Address - Fax:850-497-6219
Is Sole Proprietor?:No
Enumeration Date:2013-06-28
Last Update Date:2017-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC5023152WL0500X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL190NOOtherFLORIDA BLUE
FL014082700Medicaid
FLIA923ZMedicare PIN