MEDICARE: DR. MARK A MANARY 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	TO3364	MO

Other Identifiers

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

General Provider Information

NPI Number	:	1972594224
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK A MANARY O.D.

Provider Business Mailing Address
First Line	:	2421 W EDGEWOOD DR
Second Line	:	STE A
City	:	JEFFERSON CITY
State	:	MO
Zip	:	65109-5844
Country	:	US
Telephone Number	:	573-636-2103
Fax Number	:

Provider Business Practice Location Address
First Line	:	2421 W EDGEWOOD DR
Second Line	:	STE A
City	:	JEFFERSON CITY
State	:	MO
Zip	:	65109-5844
Country	:	US
Telephone Number	:	573-636-2103
Fax Number	:

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

Provider Enumeration Date	:	11/03/2005
Last Update Date	:	01/30/2013

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Directions to “ DR. MARK A MANARY O.D.” Practice Location

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