Provider Demographics
NPI:1467551549
Name:ALLEN, MARK H (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:H
Last Name:ALLEN
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 1:4810 LAKELAND DR
Mailing Address - Street 2:
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-8694
Mailing Address - Country:US
Mailing Address - Phone:601-932-1115
Mailing Address - Fax:601-939-3482
Practice Address - Street 1:4810 LAKELAND DR
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-8694
Practice Address - Country:US
Practice Address - Phone:601-932-1115
Practice Address - Fax:601-939-3482
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2014-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS621152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS410000275Medicare ID - Type UnspecifiedOPTOMETRIST
MSU70827Medicare UPIN