Provider Demographics
NPI:1578614418
Name:MARK, BEVERLY (OD)
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:
Last Name:MARK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2245 MORAGA ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94122-4232
Mailing Address - Country:US
Mailing Address - Phone:415-665-2809
Mailing Address - Fax:
Practice Address - Street 1:3251 20TH AVE STE 219
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94132-1918
Practice Address - Country:US
Practice Address - Phone:415-566-9292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8535152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0085350Medicare ID - Type Unspecified
CAT10701Medicare UPIN