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NPI Code Detail

MEDICARE: DR. KEION MARK O.D,

MEDICARE: DR. KEION MARK 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
1152W00000XOptometrist270A00645900NJ
2152W00000XOptometristOEG002772PA
3152W00000XOptometristOPC5282FL

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1962841072
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. KEION MARK O.D,
Provider Business Mailing Address
First Line : 2161 E COUNTY ROAD 540A # 254
Second Line :
City : LAKELAND
State : FL
Zip : 33813-3794
Country : US
Telephone Number : 484-477-2579
Fax Number :
Provider Business Practice Location Address
First Line : 801 E BAKER ST
Second Line :
City : PLANT CITY
State : FL
Zip : 33563-3652
Country : US
Telephone Number : 813-653-6100
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/21/2013
Last Update Date : 03/22/2024

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