Provider Demographics
NPI:1033402334
Name:VUKOVICH, MARK (OTR/L)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:VUKOVICH
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:MARK
Other - Middle Name:ALLAN
Other - Last Name:VUKOVICH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OTR/L
Mailing Address - Street 1:20 MILL ST
Mailing Address - Street 2:
Mailing Address - City:WILKES BARRE
Mailing Address - State:PA
Mailing Address - Zip Code:18705-3014
Mailing Address - Country:US
Mailing Address - Phone:570-574-7466
Mailing Address - Fax:
Practice Address - Street 1:20 MILL ST
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18705-3014
Practice Address - Country:US
Practice Address - Phone:570-574-7466
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-18
Last Update Date:2011-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC002603L225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist