Provider Demographics
NPI:1245239904
Name:ALLEN, MARK (OD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:ALLEN
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:PO BOX 5809
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75505-5809
Mailing Address - Country:US
Mailing Address - Phone:903-838-9063
Mailing Address - Fax:903-838-9074
Practice Address - Street 1:4401 MORRIS LANE
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503
Practice Address - Country:US
Practice Address - Phone:903-838-9063
Practice Address - Fax:903-838-9074
Is Sole Proprietor?:No
Enumeration Date:2005-07-15
Last Update Date:2012-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX05370TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1285681304OtherGROUP NPI
TX041984803Medicaid
AR132451722Medicaid
TX041984803Medicaid
TX5858490001Medicare NSC
TXU66918Medicare UPIN