Provider Demographics
NPI:1518038108
Name:CHRISTENSEN, MARK R (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:R
Last Name:CHRISTENSEN
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 1:1710 PENNSYLVANIA AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-3549
Mailing Address - Country:US
Mailing Address - Phone:707-425-2187
Mailing Address - Fax:707-434-8130
Practice Address - Street 1:1710 PENNSYLVANIA AVE
Practice Address - Street 2:SUITE B
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-3549
Practice Address - Country:US
Practice Address - Phone:707-425-2187
Practice Address - Fax:707-434-8130
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2010-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 7874 TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0078740Medicaid
CA68-0014487OtherFEDERAL TAX ID
26-0625555OtherFEDERAL TAX ID
CAT10611Medicare UPIN
CASD0078740Medicaid