Provider Demographics
NPI:1679817506
Name:LANKA, MARK R (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:R
Last Name:LANKA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:511 S PARK DR STE A
Practice Address - Street 2:
Practice Address - City:BROKEN BOW
Practice Address - State:OK
Practice Address - Zip Code:74728-5329
Practice Address - Country:US
Practice Address - Phone:580-584-3434
Practice Address - Fax:580-584-3454
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-15
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1385152W00000X
OK2857152W00000X
TX8623152W00000X
AR2714152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE1679817506Medicare PIN