Provider Demographics
NPI:1083755763
Name:LEARY, MARK EMERSON (OD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:EMERSON
Last Name:LEARY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2805 VILLAGE WAY
Mailing Address - Street 2:
Mailing Address - City:NEW BERN
Mailing Address - State:NC
Mailing Address - Zip Code:28562-7351
Mailing Address - Country:US
Mailing Address - Phone:252-633-0016
Mailing Address - Fax:252-636-3895
Practice Address - Street 1:2805 VILLAGE WAY
Practice Address - Street 2:
Practice Address - City:NEW BERN
Practice Address - State:NC
Practice Address - Zip Code:28562-7351
Practice Address - Country:US
Practice Address - Phone:252-633-0016
Practice Address - Fax:252-636-3895
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2011-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1736152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890922LMedicaid
NC0922LOtherBCBS
NC0922LOtherBCBS
NC890922LMedicaid