Provider Demographics
NPI:1598890907
Name:ROARK, MARK WILLIAM (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:WILLIAM
Last Name:ROARK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:10967 ALLISONVILLE RD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46038-2632
Mailing Address - Country:US
Mailing Address - Phone:317-577-0707
Mailing Address - Fax:317-577-1567
Practice Address - Street 1:10967 ALLISONVILLE RD
Practice Address - Street 2:SUITE 120
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46038-2632
Practice Address - Country:US
Practice Address - Phone:317-577-0707
Practice Address - Fax:317-577-1567
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN18002130A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
INT87690Medicare UPIN
IN5354490002Medicare NSC
INPTAN 224220AMedicare PIN