Provider Demographics
NPI:1295894533
Name:HEGETSCHWEILER, MARK A (OD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:HEGETSCHWEILER
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 1:550 US HIGHWAY 27
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34714-8908
Mailing Address - Country:US
Mailing Address - Phone:352-536-2746
Mailing Address - Fax:
Practice Address - Street 1:550 US HIGHWAY 27
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34714-8908
Practice Address - Country:US
Practice Address - Phone:352-536-2746
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2009-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT001101152W00000X
FLOPC2182152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAT97642Medicare UPIN
GA41ZCDJPMedicare PIN