Provider Demographics
NPI:1427193267
Name:LIVADITIS, MARK D (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:D
Last Name:LIVADITIS
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 1:5250 PORT ROYAL RD # G
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:22151-2117
Mailing Address - Country:US
Mailing Address - Phone:703-321-7780
Mailing Address - Fax:703-321-2205
Practice Address - Street 1:5250 PORT ROYAL RD # G
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22151-2117
Practice Address - Country:US
Practice Address - Phone:703-321-7780
Practice Address - Fax:703-321-2205
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2009-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000747152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA163566Medicare PIN
VAT31231Medicare UPIN