Provider Demographics
NPI:1467534420
Name:BERGER, MARK EDWARD (OD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:EDWARD
Last Name:BERGER
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 1:2400 HARDING HIGHWAY
Mailing Address - Street 2:WALMART VISION CENTER BUCKEYE DOCTORS
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45804-3428
Mailing Address - Country:US
Mailing Address - Phone:419-222-4977
Mailing Address - Fax:419-222-9940
Practice Address - Street 1:2400 HARDING HIGHWAY
Practice Address - Street 2:WALMART VISION CENTER BUCKEYE DOCTORS
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45804-3428
Practice Address - Country:US
Practice Address - Phone:419-222-4977
Practice Address - Fax:419-222-9940
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3591152W00000X
MI4901003910152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T47972Medicare UPIN