Provider Demographics
NPI:1093895690
Name:MARK D HENRY OD INC
Entity Type:Organization
Organization Name:MARK D HENRY OD INC
Other - Org Name:PRIMARY VISION CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTICIAN
Authorized Official - Prefix:
Authorized Official - First Name:AMBER
Authorized Official - Middle Name:
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:
Authorized Official - Credentials:LDO
Authorized Official - Phone:740-654-9909
Mailing Address - Street 1:1213 N MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:OH
Mailing Address - Zip Code:43130-1626
Mailing Address - Country:US
Mailing Address - Phone:740-654-9909
Mailing Address - Fax:740-654-9969
Practice Address - Street 1:1213 N MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:OH
Practice Address - Zip Code:43130-1626
Practice Address - Country:US
Practice Address - Phone:740-654-9909
Practice Address - Fax:740-654-9969
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2455141Medicaid
OH2455141Medicaid
OHMA9341191Medicare ID - Type Unspecified