=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467550731
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARK HUMPHRIES JR. OD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2006
-----------------------------------------------------
Last Update Date | 08/22/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 21611 VILLAGE LAKES SHOPPING CENTER
-----------------------------------------------------
City | LAND O LAKES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34639-5102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-949-1982
-----------------------------------------------------
Fax | 813-949-0422
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 21611 VILLAGE LAKES SHOPPING CENTER
-----------------------------------------------------
City | LAND O LAKES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34639-5102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-949-1982
-----------------------------------------------------
Fax | 813-949-0422
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OPC001159
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 776
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 674
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------