MEDICARE: DR. MARK R CHRISTENSEN O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	OPT 7874 TPA	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	68-0014487	OTHER	CA	FEDERAL TAX ID
3	26-0625555	OTHER		FEDERAL TAX ID

General Provider Information

NPI Number	:	1518038108
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK R CHRISTENSEN O.D.

Provider Business Mailing Address
First Line	:	1710 PENNSYLVANIA AVE
Second Line	:	SUITE B
City	:	FAIRFIELD
State	:	CA
Zip	:	94533-3549
Country	:	US
Telephone Number	:	707-425-2187
Fax Number	:	707-434-8130

Provider Business Practice Location Address
First Line	:	1710 PENNSYLVANIA AVE
Second Line	:	SUITE B
City	:	FAIRFIELD
State	:	CA
Zip	:	94533-3549
Country	:	US
Telephone Number	:	707-425-2187
Fax Number	:	707-434-8130

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/13/2006
Last Update Date	:	02/08/2010

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