Provider Demographics
NPI:1265408827
Name:ROEMMICH, MARK D (OD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:D
Last Name:ROEMMICH
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 1:205 W BLACKSTOCK RD STE 150
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29301-3205
Mailing Address - Country:US
Mailing Address - Phone:864-574-8454
Mailing Address - Fax:
Practice Address - Street 1:15 WOLF DEN DR
Practice Address - Street 2:
Practice Address - City:GREER
Practice Address - State:SC
Practice Address - Zip Code:29650-2985
Practice Address - Country:US
Practice Address - Phone:864-630-4631
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-24
Last Update Date:2010-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC1010152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1265408827OtherNPI
SCD10101Medicaid
SCU447400281Medicare ID - Type Unspecified
SCU44740Medicare UPIN