Provider Demographics
NPI:1649381518
Name:VETH, MARK EDWARD (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:EDWARD
Last Name:VETH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:503 DOCTORS CT
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54901-2025
Mailing Address - Country:US
Mailing Address - Phone:920-236-3540
Mailing Address - Fax:920-236-3546
Practice Address - Street 1:437 N PIONEER RD
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-2087
Practice Address - Country:US
Practice Address - Phone:920-923-0000
Practice Address - Fax:920-923-5601
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI2956035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38622200Medicaid
WIU98486Medicare UPIN