Provider Demographics
NPI:1902864390
Name:EMMERICH, MARK A (OD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:EMMERICH
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 1:34 FIRST STREET EAST
Mailing Address - Street 2:
Mailing Address - City:DICKINSON
Mailing Address - State:ND
Mailing Address - Zip Code:58601-5106
Mailing Address - Country:US
Mailing Address - Phone:701-225-9601
Mailing Address - Fax:701-483-9601
Practice Address - Street 1:34 FIRST STREET EAST
Practice Address - Street 2:
Practice Address - City:DICKINSON
Practice Address - State:ND
Practice Address - Zip Code:58601-5106
Practice Address - Country:US
Practice Address - Phone:701-225-9601
Practice Address - Fax:701-483-9601
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-03
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND379152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND800379OtherNDVS
410004275OtherTRAVLERS
NDEMM8814OtherBCBS
ND60252Medicaid
ND800379OtherNDVS
ND60252Medicaid
NDN8814Medicare PIN