Provider Demographics
NPI:1487621678
Name:HOHENBERGER, MARY C (OD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:C
Last Name:HOHENBERGER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 E BROADWAY
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-6220
Mailing Address - Country:US
Mailing Address - Phone:618-462-9818
Mailing Address - Fax:800-432-6004
Practice Address - Street 1:935 N HIGHWAY 67
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63031-2917
Practice Address - Country:US
Practice Address - Phone:314-838-7644
Practice Address - Fax:800-432-6004
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOTO2898152W00000X
IL046-008348152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
22-02300OtherOPTICARE MEDICARE COMPLET
IL410048082OtherRR MEDICARE
MO4182OtherHEALTHCARE USA
215634OtherGHP
MO110973OtherEYEMED
MO313059214Medicaid
MOP00402868OtherRR MEDICARE
382671OtherHEALTHLINK
MO000091342OtherMEDICARE PART B
MO108046OtherBLUE CROSS BLUE SHIELD OF
MO22-02300OtherUNITED HEALTHCARE
MO313059206Medicaid
MO000091353Medicare PIN
MO000091342OtherMEDICARE PART B
ILK04091Medicare PIN
MO313059214Medicaid