Provider Demographics
NPI:1588646673
Name:GOTCHER, MARK (OD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:GOTCHER
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:PO BOX 626
Mailing Address - Street 2:
Mailing Address - City:COTTAGE GROVE
Mailing Address - State:OR
Mailing Address - Zip Code:97424-0027
Mailing Address - Country:US
Mailing Address - Phone:541-942-0176
Mailing Address - Fax:541-942-0177
Practice Address - Street 1:315 S PACIFIC HWY 99
Practice Address - Street 2:
Practice Address - City:COTTAGE GROVE
Practice Address - State:OR
Practice Address - Zip Code:97424-2137
Practice Address - Country:US
Practice Address - Phone:541-942-0176
Practice Address - Fax:541-942-0177
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-15
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2529AT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR208414Medicaid
ORU61415Medicare UPIN
OR208414Medicaid
ORR105767Medicare PIN