Provider Demographics
NPI:1386631034
Name:WEINTRAUB, MARK (OD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:WEINTRAUB
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 1:1355 4TH ST
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90401-1301
Mailing Address - Country:US
Mailing Address - Phone:310-394-1011
Mailing Address - Fax:310-451-0153
Practice Address - Street 1:1355 4TH ST
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90401-1301
Practice Address - Country:US
Practice Address - Phone:310-394-1011
Practice Address - Fax:310-451-0153
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-27
Last Update Date:2011-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA70857T332H00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT70172Medicare UPIN
0622410001Medicare NSC
CAFA908AMedicare PIN