Provider Demographics
NPI:1821070103
Name:IVENS, MARK Y (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:Y
Last Name:IVENS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4528 CHAPMAN HWY
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37920-4359
Mailing Address - Country:US
Mailing Address - Phone:865-579-3920
Mailing Address - Fax:865-579-3963
Practice Address - Street 1:4528 CHAPMAN HWY
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37920-4359
Practice Address - Country:US
Practice Address - Phone:865-579-3920
Practice Address - Fax:865-579-3918
Is Sole Proprietor?:No
Enumeration Date:2005-11-14
Last Update Date:2020-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD11712207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3199121Medicaid
TN3199122Medicare Oscar/Certification
TNB59552Medicare UPIN
TN3199121Medicaid