Provider Demographics
NPI:1558417949
Name:BANNON, MARK JOSEPH (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:JOSEPH
Last Name:BANNON
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 1:359 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:KENSINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06037-2651
Mailing Address - Country:US
Mailing Address - Phone:860-829-1020
Mailing Address - Fax:860-828-5246
Practice Address - Street 1:359 MAIN ST
Practice Address - Street 2:
Practice Address - City:KENSINGTON
Practice Address - State:CT
Practice Address - Zip Code:06037-2651
Practice Address - Country:US
Practice Address - Phone:860-829-1020
Practice Address - Fax:860-828-5246
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2008-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT888152W00000X, 332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
No152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004101549Medicaid
CT004101549Medicaid
CT410000602Medicare PIN
CT0665950001Medicare NSC