Provider Demographics
NPI:1770694267
Name:BUEHNERKEMPER, MARK LOUIS (OD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:LOUIS
Last Name:BUEHNERKEMPER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3150 BELL HILL RD
Mailing Address - Street 2:
Mailing Address - City:KELSEYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95451-8317
Mailing Address - Country:US
Mailing Address - Phone:707-279-1032
Mailing Address - Fax:
Practice Address - Street 1:120 SOUTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:LAKEPORT
Practice Address - State:CA
Practice Address - Zip Code:95453-5017
Practice Address - Country:US
Practice Address - Phone:707-263-4294
Practice Address - Fax:707-263-5180
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2011-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10676152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0106760 1532330Medicaid
CASD0106760 1532330Medicaid
CA1162030001Medicare NSC
CAU64517Medicare UPIN