Provider Demographics
NPI:1659446342
Name:DENEGRE, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:DENEGRE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 MAIN ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CENTERBROOK
Mailing Address - State:CT
Mailing Address - Zip Code:06409-1056
Mailing Address - Country:US
Mailing Address - Phone:860-767-3206
Mailing Address - Fax:860-767-0836
Practice Address - Street 1:90 MAIN ST
Practice Address - Street 2:SUITE 101
Practice Address - City:CENTERBROOK
Practice Address - State:CT
Practice Address - Zip Code:06409-1056
Practice Address - Country:US
Practice Address - Phone:860-767-3206
Practice Address - Fax:860-767-0836
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT780156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT200001396CT01OtherANTHEM
CT1909OtherDAVIS VISION
CT1909OtherDAVIS VISION