Healthcare Provider Details

I. General information

NPI: 1710966817
Provider Name (Legal Business Name): MARK DAVID PIFER O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2006
Last Update Date: 10/21/2020
Certification Date: 10/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1355 W MAIN ST SUITE A
BELLEVUE OH
44811-9082
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 419-483-7685
  • Fax: 419-483-4694
Mailing address:
  • Phone: 703-847-8899
  • Fax: 571-223-6780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3486
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: