Individual
DR. JOHN MARK DEBOER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
O.D.
Contact information
Practice address
609 N HALLECK ST, DEMOTTE, IN 46310-9545
(219) 987-3673
(219) 987-3905
Mailing address
PO BOX 849, DEMOTTE, IN 46310-0849
(219) 987-3673
(219) 987-3905
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
046-008335
IL
152W00000X
Optometrist
Primary
18002449
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
200395230
—
IN
01
—
K48802
MEDICARE PTAN
IL
Enumeration date
11/25/2005
Last updated
09/02/2010
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