MEDICARE: DR. MARK ANDREW GENDAL O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	OPC1601	FL

General Provider Information

NPI Number	:	1629167150
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK ANDREW GENDAL O.D.

Provider Business Mailing Address
First Line	:	2059 N UNIVERSITY DR
Second Line	:
City	:	CORAL SPRINGS
State	:	FL
Zip	:	33071-6132
Country	:	US
Telephone Number	:	954-752-0589
Fax Number	:	954-753-1101

Provider Business Practice Location Address
First Line	:	2059 N UNIVERSITY DR
Second Line	:
City	:	CORAL SPRINGS
State	:	FL
Zip	:	33071-6132
Country	:	US
Telephone Number	:	954-752-0589
Fax Number	:	954-753-1101

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/12/2006
Last Update Date	:	07/08/2007

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