Provider Demographics
NPI:1821125485
Name:MARK R. KAPPERMAN, OD PC
Entity Type:Organization
Organization Name:MARK R. KAPPERMAN, OD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:R
Authorized Official - Last Name:KAPPERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:423-892-2020
Mailing Address - Street 1:1720 GUNBARREL RD STE 100
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-3192
Mailing Address - Country:US
Mailing Address - Phone:423-892-2020
Mailing Address - Fax:423-855-0329
Practice Address - Street 1:1720 GUNBARREL RD STE 100
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-3192
Practice Address - Country:US
Practice Address - Phone:423-892-2020
Practice Address - Fax:423-855-0329
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN001120-TNOD152W00000X
TN001996152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0922230001Medicare NSC
TNT-61322Medicare UPIN
TN3596542Medicare PIN
TN3942905Medicare PIN
TNU76888Medicare UPIN
TN3943106Medicare PIN
TN3596543Medicare PIN