Provider Demographics
NPI:1205814779
Name:NOSS, MARK D (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:D
Last Name:NOSS
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 1:328 MUNSON AVE
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686-3040
Mailing Address - Country:US
Mailing Address - Phone:231-946-8460
Mailing Address - Fax:231-946-8507
Practice Address - Street 1:328 MUNSON AVE
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-3040
Practice Address - Country:US
Practice Address - Phone:231-946-8460
Practice Address - Fax:231-946-8507
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2011-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002760152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
900B865060OtherBCBS
MI945088450Medicaid
900B865060OtherBCBS
MI945088450Medicaid