Provider Demographics
NPI:1730488156
Name:SCHANBAUM, MARK LEE (ABOC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:LEE
Last Name:SCHANBAUM
Suffix:
Gender:M
Credentials:ABOC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2540 KING ARTHUR BLVD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75056-5512
Mailing Address - Country:US
Mailing Address - Phone:972-899-1222
Mailing Address - Fax:972-899-1222
Practice Address - Street 1:2540 KING ARTHUR BLVD
Practice Address - Street 2:SUITE 103
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75056-5512
Practice Address - Country:US
Practice Address - Phone:972-899-1222
Practice Address - Fax:972-899-1222
Is Sole Proprietor?:No
Enumeration Date:2011-03-24
Last Update Date:2011-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10503156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician