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General NPI Number Information
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NPI Number | 1871649202
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Entity Type | Individual
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Provider Name | TERRI JUSTINE MARK O.D.
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Gender | Female
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Dates
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Enumeration Date | 01/26/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 37 BOVET RD
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City | SAN MATEO
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State | CA
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Zip | 94402-3104
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Country | US
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Telephone | 650-570-5955
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Fax | 650-570-7124
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Provider Business Mailing Address
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Address Line | 225 ROSILIE ST
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City | SAN MATEO
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State | CA
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Zip | 94403-4912
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Country | US
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Telephone | 650-522-9969
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 10634T
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License Number State | CA
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