Provider Demographics
NPI:1497836829
Name:YORGENSEN, MARK D (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:D
Last Name:YORGENSEN
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 1:116 CHENEY RD
Mailing Address - Street 2:
Mailing Address - City:MARLBOROUGH
Mailing Address - State:CT
Mailing Address - Zip Code:06447-1331
Mailing Address - Country:US
Mailing Address - Phone:860-985-9860
Mailing Address - Fax:
Practice Address - Street 1:220 SALEM TPKE
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:CT
Practice Address - Zip Code:06360-6455
Practice Address - Country:US
Practice Address - Phone:860-985-9860
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2454152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTU72200Medicare UPIN