Provider Demographics
NPI:1811991391
Name:BERNTHAL, MARK E (OD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:E
Last Name:BERNTHAL
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 1:21711 GREATER MACK AVE
Mailing Address - Street 2:
Mailing Address - City:ST CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-2418
Mailing Address - Country:US
Mailing Address - Phone:586-774-0393
Mailing Address - Fax:
Practice Address - Street 1:21711 GREATER MACK AVE
Practice Address - Street 2:
Practice Address - City:ST CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-2418
Practice Address - Country:US
Practice Address - Phone:586-774-0393
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002685152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0218080001OtherDMERC
MI410016688OtherMEDICARE RAILROAD
MI0E06612Medicare PIN
MIT33221Medicare UPIN