Healthcare Provider Details

I. General information

NPI: 1740226752
Provider Name (Legal Business Name): MARK DAVID STURGIS O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2006
Last Update Date: 12/29/2020
Certification Date: 12/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29 BUCKLAND ST
MANCHESTER CT
06042-1601
US

IV. Provider business mailing address

1950 OLD GALLOWS RD STE 520
VIENNA VA
22182-3970
US

V. Phone/Fax

Practice location:
  • Phone: 860-646-6655
  • Fax: 860-647-7872
Mailing address:
  • Phone: 703-847-8899
  • Fax: 571-223-6780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number2010
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code152WX0102X
TaxonomyOccupational Vision Optometrist
License Number2010
License Number StateCT
# 3
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2010
License Number StateCT
# 4
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number2010
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: