Provider Demographics
NPI:1619936481
Name:LEHMANN, MARK MATTHEW (OD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:MATTHEW
Last Name:LEHMANN
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 1:1394 FRIANT DR
Mailing Address - Street 2:
Mailing Address - City:S LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150-8061
Mailing Address - Country:US
Mailing Address - Phone:530-541-2030
Mailing Address - Fax:536-541-3947
Practice Address - Street 1:2074 LAKE TAHOE BLVD STE 2
Practice Address - Street 2:
Practice Address - City:S LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150-6408
Practice Address - Country:US
Practice Address - Phone:530-541-2030
Practice Address - Fax:536-541-3947
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10225T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA3111526Medicaid
ML1050753OtherDEA
ZZZ75623ZMedicare ID - Type Unspecified
CA3111526Medicaid