Provider Demographics
NPI:1225089295
Name:POPP, MARK ALAN (OD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ALAN
Last Name:POPP
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:447 ATLANTIC BLVD
Mailing Address - Street 2:
Mailing Address - City:ATLANTIC BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32233-4050
Mailing Address - Country:US
Mailing Address - Phone:904-247-0211
Mailing Address - Fax:904-246-6115
Practice Address - Street 1:447 ATLANTIC BLVD
Practice Address - Street 2:
Practice Address - City:ATLANTIC BEACH
Practice Address - State:FL
Practice Address - Zip Code:32233-4004
Practice Address - Country:US
Practice Address - Phone:904-247-0211
Practice Address - Fax:904-246-6115
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-15
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC1956152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL078899600Medicaid
FLT84241Medicare UPIN
FL19377Medicare ID - Type Unspecified