Provider Demographics
NPI:1255389201
Name:EBBEN, MARK ARTHUR (OD OPTOMETRIST)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:ARTHUR
Last Name:EBBEN
Suffix:
Gender:M
Credentials:OD OPTOMETRIST
Other - Prefix:DR
Other - First Name:MARK
Other - Middle Name:ARTHUR
Other - Last Name:EBBEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LLC OPTOMETRIST
Mailing Address - Street 1:1 BANK AVE
Mailing Address - Street 2:
Mailing Address - City:KAUKAUNA
Mailing Address - State:WI
Mailing Address - Zip Code:54130
Mailing Address - Country:US
Mailing Address - Phone:920-766-2481
Mailing Address - Fax:920-766-3769
Practice Address - Street 1:1 BANK AVE
Practice Address - Street 2:
Practice Address - City:KAUKAUNA
Practice Address - State:WI
Practice Address - Zip Code:54130-2581
Practice Address - Country:US
Practice Address - Phone:920-766-2481
Practice Address - Fax:920-766-3769
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1618035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38700400Medicaid
WI38700400Medicaid
WIT61830Medicare UPIN
410046493Medicare PIN
0191750001Medicare NSC
WI38700400Medicaid