Basic Information
| Provider Information | |||||||||
| NPI: | 1376983874 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OBENCHAIN | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | ALLEN | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15933 CLAYTON RD | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | BALLWIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630112172 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6362004393 | ||||||||
| FaxNumber: | 6365270838 | ||||||||
| Practice Location | |||||||||
| Address1: | 5101 N. DAVIS HWY | ||||||||
| Address2: | SUITE A | ||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325032040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504797379 | ||||||||
| FaxNumber: | 8504976219 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2013 | ||||||||
| LastUpdateDate: | 08/07/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152WL0500X | OPC5023 | FL | N | Eye and Vision Services Providers | Optometrist | Low Vision Rehabilitation | 152W00000X | OPC5023 | FL | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 190NO | 01 | FL | FLORIDA BLUE | OTHER | 014082700 | 05 | FL | MEDICAID |