1619936481 NPI number — MARK MATTHEW LEHMANN OD

Table of content: MARK MATTHEW LEHMANN OD (NPI 1619936481)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619936481 NPI number — MARK MATTHEW LEHMANN OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEHMANN
Provider First Name:
MARK
Provider Middle Name:
MATTHEW
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:
1619936481
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1394 FRIANT DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
S LAKE TAHOE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
96150-8061
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
530-541-2030
Provider Business Mailing Address Fax Number:
536-541-3947

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2074 LAKE TAHOE BLVD STE 2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
S LAKE TAHOE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
96150-6408
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-541-2030
Provider Business Practice Location Address Fax Number:
536-541-3947
Provider Enumeration Date:
03/21/2006

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:  10225T , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3111526 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".