Provider Demographics
NPI:1558676064
Name:MARK L HEPNER OPTOMETRIST LLC
Entity Type:Organization
Organization Name:MARK L HEPNER OPTOMETRIST LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:L
Authorized Official - Last Name:HEPNER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:570-286-2541
Mailing Address - Street 1:309 N 5TH ST
Mailing Address - Street 2:
Mailing Address - City:SUNBURY
Mailing Address - State:PA
Mailing Address - Zip Code:17801-2000
Mailing Address - Country:US
Mailing Address - Phone:570-286-2541
Mailing Address - Fax:570-286-4180
Practice Address - Street 1:309 N 5TH ST
Practice Address - Street 2:
Practice Address - City:SUNBURY
Practice Address - State:PA
Practice Address - Zip Code:17801-2000
Practice Address - Country:US
Practice Address - Phone:570-286-2541
Practice Address - Fax:570-286-4180
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-10
Last Update Date:2014-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOE007711-P152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
197342Medicare PIN
U54357Medicare UPIN
PA01521138Medicaid
HE468663Medicare PIN