Healthcare Provider Details

I. General information

NPI: 1053534347
Provider Name (Legal Business Name): ST MARKS EYE INSTITUTE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 06/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

502 S 'M' ST
TACOMA WA
98405
US

IV. Provider business mailing address

502 S 'M' ST
TACOMA WA
98405
US

V. Phone/Fax

Practice location:
  • Phone: 253-627-8266
  • Fax: 253-572-7839
Mailing address:
  • Phone: 253-627-8266
  • Fax: 253-572-7839

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number601477860
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number14833
License Number StateWA

VIII. Authorized Official

Name: DR. DOUGLAS ANTHONY MACLEOD
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 253-627-8266