Provider Demographics
NPI:1205834439
Name:PACKER, MARK (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:PACKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 BLUEBELL AVE
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80302-7834
Mailing Address - Country:US
Mailing Address - Phone:541-915-0291
Mailing Address - Fax:
Practice Address - Street 1:1400 BLUEBELL AVE
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80302-7834
Practice Address - Country:US
Practice Address - Phone:541-915-0291
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2018-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD22302207W00000X
CA75599207W00000X
CODR.0054602207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR130311Medicaid
180043385OtherRAILROAD MEDICARE
180040741OtherRAILROAD MEDICARE
180040741OtherRAILROAD MEDICARE
OR130311Medicaid
R106460Medicare PIN