Healthcare Provider Details

I. General information

NPI: 1912979311
Provider Name (Legal Business Name): MARK C. HURST OPTOMETRIST, LTD.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: MARK C. HURST O.D.

II. Dates (important events)

Enumeration Date: 02/02/2006
Last Update Date: 06/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 WESTWOOD DRIVE
MT VERNON IL
62864
US

IV. Provider business mailing address

4 WESTWOOD DRIVE
MT VERNON IL
62864
US

V. Phone/Fax

Practice location:
  • Phone: 618-242-7810
  • Fax: 618-242-1867
Mailing address:
  • Phone: 618-242-7810
  • Fax: 618-242-1867

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046007393
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: