Provider Demographics
NPI:1639400112
Name:DR. MARK R. WOLMER, P.C.
Entity Type:Organization
Organization Name:DR. MARK R. WOLMER, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:WOLMER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:203-792-2020
Mailing Address - Street 1:62 NORTH ST
Mailing Address - Street 2:
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06810-5620
Mailing Address - Country:US
Mailing Address - Phone:203-792-2020
Mailing Address - Fax:203-792-9998
Practice Address - Street 1:62 NORTH ST
Practice Address - Street 2:
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-5620
Practice Address - Country:US
Practice Address - Phone:203-792-2020
Practice Address - Fax:203-792-9998
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-22
Last Update Date:2010-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT711152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1588644033OtherPERSONAL NPI
CTD100010508Medicare PIN
410000213Medicare UPIN