Provider Demographics
NPI:1750482659
Name:GIVENS, MARK BRUCE (OD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:BRUCE
Last Name:GIVENS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 110567
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37222-0567
Mailing Address - Country:US
Mailing Address - Phone:931-553-2132
Mailing Address - Fax:931-552-7446
Practice Address - Street 1:2801 WILMA RUDOLPH BLVD
Practice Address - Street 2:SUITE #100
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37040-5011
Practice Address - Country:US
Practice Address - Phone:931-553-2132
Practice Address - Fax:931-552-7446
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2011-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN499152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3592519Medicare ID - Type Unspecified
U01047Medicare UPIN