Provider Demographics
NPI:1437258944
Name:HETHERINGTON, MARK C (OD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:C
Last Name:HETHERINGTON
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 1:3435 49TH ST N
Mailing Address - Street 2:SUITE A
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33710-2147
Mailing Address - Country:US
Mailing Address - Phone:727-522-8423
Mailing Address - Fax:727-521-1886
Practice Address - Street 1:3435 49TH ST N
Practice Address - Street 2:SUITE A
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-2147
Practice Address - Country:US
Practice Address - Phone:727-522-8423
Practice Address - Fax:727-521-1886
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2016-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC2813152W00000X
FLOPC-2183152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLUO8959Medicare UPIN
KYU08959Medicare UPIN