Provider Demographics
NPI:1275527467
Name:HENRY, MARK DAVID (OD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:DAVID
Last Name:HENRY
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 1:784 E MAIN ST STE D
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:OH
Mailing Address - Zip Code:43130-3983
Mailing Address - Country:US
Mailing Address - Phone:740-654-9909
Mailing Address - Fax:740-654-9969
Practice Address - Street 1:784 E MAIN ST STE D
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:OH
Practice Address - Zip Code:43130-3983
Practice Address - Country:US
Practice Address - Phone:740-654-9909
Practice Address - Fax:740-654-9969
Is Sole Proprietor?:No
Enumeration Date:2005-09-02
Last Update Date:2017-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4713-T1502152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2197251Medicaid
OHU57542Medicare UPIN
OH2197251Medicaid