Provider Demographics
NPI:1851437479
Name:MAXON, MARK RAYMOND (OD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:RAYMOND
Last Name:MAXON
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 1:720 UNIVERSITY AVE
Mailing Address - Street 2:STE 110
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-1702
Mailing Address - Country:US
Mailing Address - Phone:315-425-0373
Mailing Address - Fax:315-425-0374
Practice Address - Street 1:720 UNIVERSITY AVE
Practice Address - Street 2:STE 110
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1702
Practice Address - Country:US
Practice Address - Phone:315-425-0373
Practice Address - Fax:315-425-0373
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV0051831152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U16593Medicare UPIN