=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295894533
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARK A. HEGETSCHWEILER O.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/06/2006
-----------------------------------------------------
Last Update Date | 12/28/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 550 US HIGHWAY 27
-----------------------------------------------------
City | CLERMONT
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34714-8908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-536-2746
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 550 US HIGHWAY 27
-----------------------------------------------------
City | CLERMONT
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34714-8908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-536-2746
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OPT001101
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OPC2182
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------