Provider Demographics
NPI:1467550731
Name:HUMPHRIES, MARK JR (OD)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:HUMPHRIES
Suffix:JR
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 1:21611 VILLAGE LAKES SHOPPING CENTER
Mailing Address - Street 2:
Mailing Address - City:LAND O LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:34639-5102
Mailing Address - Country:US
Mailing Address - Phone:813-949-1982
Mailing Address - Fax:813-949-0422
Practice Address - Street 1:21611 VILLAGE LAKES SHOPPING CENTER
Practice Address - Street 2:
Practice Address - City:LAND O LAKES
Practice Address - State:FL
Practice Address - Zip Code:34639-5102
Practice Address - Country:US
Practice Address - Phone:813-949-1982
Practice Address - Fax:813-949-0422
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2008-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC001159152W00000X
LA776152W00000X
MS674152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL38918OtherDAVIS
FL084928600Medicaid
FL19161AOtherBCBS FL
FL101718OtherAUMED
FL38918OtherDAVIS
19161AMedicare PIN