Provider Demographics
NPI:1952472342
Name:REBECK, MARK JOSEPH (OD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:JOSEPH
Last Name:REBECK
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 1:1353A SOUTH MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27215-5768
Mailing Address - Country:US
Mailing Address - Phone:336-222-8887
Mailing Address - Fax:
Practice Address - Street 1:1353A SOUTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27215-5768
Practice Address - Country:US
Practice Address - Phone:336-222-8887
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1104152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
246406CMedicare ID - Type Unspecified
T64942Medicare UPIN