Provider Demographics
NPI:1457304701
Name:HOLLIDAY, MARK EDWARD (OD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:EDWARD
Last Name:HOLLIDAY
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 1:1928 HARPER RD
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-2612
Mailing Address - Country:US
Mailing Address - Phone:304-252-1299
Mailing Address - Fax:304-253-4079
Practice Address - Street 1:1928 HARPER RD
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-2612
Practice Address - Country:US
Practice Address - Phone:304-252-1299
Practice Address - Fax:304-253-4079
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2010-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV817 OD152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV2002000000Medicaid
WV9314511Medicare ID - Type UnspecifiedMEDICARE
WV2002000000Medicaid