Provider Demographics
NPI:1770566556
Name:DEBOER, JOHN MARK (OD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MARK
Last Name:DEBOER
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 849
Mailing Address - Street 2:
Mailing Address - City:DEMOTTE
Mailing Address - State:IN
Mailing Address - Zip Code:46310-0849
Mailing Address - Country:US
Mailing Address - Phone:219-987-3673
Mailing Address - Fax:219-987-3905
Practice Address - Street 1:609 N HALLECK ST
Practice Address - Street 2:
Practice Address - City:DEMOTTE
Practice Address - State:IN
Practice Address - Zip Code:46310-9545
Practice Address - Country:US
Practice Address - Phone:219-987-3673
Practice Address - Fax:219-987-3905
Is Sole Proprietor?:No
Enumeration Date:2005-11-25
Last Update Date:2010-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002449152W00000X
IL046-008335152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200395230Medicaid
ILK48802OtherMEDICARE PTAN
INU09018Medicare UPIN
ILK48802OtherMEDICARE PTAN