Provider Demographics
NPI:1114082039
Name:LABHART, MARK (OD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:LABHART
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 1:715 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TELL CITY
Mailing Address - State:IN
Mailing Address - Zip Code:47586-1705
Mailing Address - Country:US
Mailing Address - Phone:812-547-3396
Mailing Address - Fax:812-547-5272
Practice Address - Street 1:715 MAIN ST
Practice Address - Street 2:
Practice Address - City:TELL CITY
Practice Address - State:IN
Practice Address - Zip Code:47586-1705
Practice Address - Country:US
Practice Address - Phone:812-547-3396
Practice Address - Fax:812-547-5272
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2013-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1800318152W00000X
KY1549DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200453070AMedicaid
IN200453070AMedicaid
IN196350VMedicare ID - Type UnspecifiedOD PIN