Provider Demographics
NPI:1538268388
Name:WINCKLER, MARK R (OD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:R
Last Name:WINCKLER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 399
Mailing Address - Street 2:
Mailing Address - City:PINE RIDGE
Mailing Address - State:SD
Mailing Address - Zip Code:57770-0399
Mailing Address - Country:US
Mailing Address - Phone:605-867-2772
Mailing Address - Fax:
Practice Address - Street 1:207 E MAIN ST STE 1
Practice Address - Street 2:
Practice Address - City:PINE RIDGE
Practice Address - State:SD
Practice Address - Zip Code:57770-3184
Practice Address - Country:US
Practice Address - Phone:605-867-2772
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD631152W00000X
NE1269152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE09902OtherBCBS OF NE
SD4993077OtherWELLMARK BCBS
SD9203683Medicaid
SD9203680Medicaid
NEP00390774OtherRR MEDICARE
SD9203682Medicaid
NE280910Medicare PIN
SDS101738Medicare PIN
NEP00390774OtherRR MEDICARE
NE09902OtherBCBS OF NE
SD4993077OtherWELLMARK BCBS
NE280911Medicare PIN