Provider Demographics
NPI: | 1730111501 |
---|---|
Name: | MARK LYNN OD & ASSOCIATES PC |
Entity Type: | Organization |
Organization Name: | MARK LYNN OD & ASSOCIATES PC |
Other - Org Name: | DOCTOR'S VISIONWORKS |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | OWNER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | MARK |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | LYNN |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | OD |
Authorized Official - Phone: | 812-285-5050 |
Mailing Address - Street 1: | PO BOX 848560 |
Mailing Address - Street 2: | |
Mailing Address - City: | DALLAS |
Mailing Address - State: | TX |
Mailing Address - Zip Code: | 75284-8560 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 210-524-6663 |
Mailing Address - Fax: | 210-524-6587 |
Practice Address - Street 1: | 1245 CUMBERLAND MALL |
Practice Address - Street 2: | |
Practice Address - City: | ATLANTA |
Practice Address - State: | GA |
Practice Address - Zip Code: | 30339-3136 |
Practice Address - Country: | US |
Practice Address - Phone: | 770-434-0440 |
Practice Address - Fax: | 770-434-5460 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2006-07-06 |
Last Update Date: | 2009-06-23 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 332H00000X | Suppliers | Eyewear Supplier |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
GA | 5763790001 | Medicare NSC |