Healthcare Provider Details

I. General information

NPI: 1295894533
Provider Name (Legal Business Name): MARK A. HEGETSCHWEILER O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 12/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 US HIGHWAY 27
CLERMONT FL
34714-8908
US

IV. Provider business mailing address

550 US HIGHWAY 27
CLERMONT FL
34714-8908
US

V. Phone/Fax

Practice location:
  • Phone: 352-536-2746
  • Fax:
Mailing address:
  • Phone: 352-536-2746
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT001101
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC2182
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: