Healthcare Provider Details

I. General information

NPI: 1265438766
Provider Name (Legal Business Name): MARK R BARKER OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2005
Last Update Date: 03/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7177 MAIN ST
BONNERS FERRY ID
83805
US

IV. Provider business mailing address

PO BOX U
BONNERS FERRY ID
83805-1280
US

V. Phone/Fax

Practice location:
  • Phone: 208-267-2020
  • Fax: 208-267-8748
Mailing address:
  • Phone: 208-267-2020
  • Fax: 208-267-8748

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0-541
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: