Provider Demographics
NPI:1396880787
Name:MEWBORNE, MARK C (OD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:C
Last Name:MEWBORNE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:43927 15TH ST W
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93534-4758
Mailing Address - Country:US
Mailing Address - Phone:661-948-6310
Mailing Address - Fax:661-948-6880
Practice Address - Street 1:43927 15TH ST W
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-4758
Practice Address - Country:US
Practice Address - Phone:661-948-6310
Practice Address - Fax:661-948-6880
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2010-12-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA7920T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOP7920Medicare PIN
CA1192710001Medicare NSC
CAU40535Medicare UPIN