Provider Demographics
NPI:1831277367
Name:TOELLE, MARK ALLAN (OD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALLAN
Last Name:TOELLE
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 1:14450 EAGLE RUN DR STE 140
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68116
Mailing Address - Country:US
Mailing Address - Phone:402-884-0776
Mailing Address - Fax:
Practice Address - Street 1:14450 EAGLE RUN DR STE 140
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68116
Practice Address - Country:US
Practice Address - Phone:402-884-0776
Practice Address - Fax:402-884-0749
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2018-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NENE1146152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE277050Medicare PIN
NEP00716276Medicare PIN
NEU78554Medicare UPIN