Provider Demographics
NPI:1063609063
Name:MARK GOTCHER OD
Entity type:Organization
Organization Name:MARK GOTCHER OD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:F
Authorized Official - Last Name:GOTCHER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:541-942-0176
Mailing Address - Street 1:PO BOX 626
Mailing Address - Street 2:
Mailing Address - City:COTTAGE GROVE
Mailing Address - State:OR
Mailing Address - Zip Code:97424-0027
Mailing Address - Country:US
Mailing Address - Phone:541-942-0176
Mailing Address - Fax:541-942-0177
Practice Address - Street 1:315 S PACIFIC HWY 99
Practice Address - Street 2:
Practice Address - City:COTTAGE GROVE
Practice Address - State:OR
Practice Address - Zip Code:97424-2137
Practice Address - Country:US
Practice Address - Phone:541-942-0176
Practice Address - Fax:541-942-0177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-03
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2529ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR208414Medicaid
OR208414Medicaid
OR1296340001Medicare NSC
ORU61415Medicare UPIN