1538268388 NPI number — MARK R WINCKLER OD

Table of content: MARK R WINCKLER OD (NPI 1538268388)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538268388 NPI number — MARK R WINCKLER OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WINCKLER
Provider First Name:
MARK
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1538268388
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/03/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 399
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PINE RIDGE
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57770-0399
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-867-2772
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
207 E MAIN ST STE 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PINE RIDGE
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57770-3184
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-867-2772
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  631 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X , with the licence number: 1269 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 09902 . This is a "BCBS OF NE" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 4993077 . This is a "WELLMARK BCBS" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 9203683 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9203680 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00390774 . This is a "RR MEDICARE" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 9203682 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".




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