Provider Demographics
NPI:1871649202
Name:MARK, TERRI JUSTINE (OD)
Entity Type:Individual
Prefix:DR
First Name:TERRI
Middle Name:JUSTINE
Last Name:MARK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:225 ROSILIE ST
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94403-4912
Mailing Address - Country:US
Mailing Address - Phone:650-522-9969
Mailing Address - Fax:
Practice Address - Street 1:37 BOVET RD
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94402-3104
Practice Address - Country:US
Practice Address - Phone:650-570-5955
Practice Address - Fax:650-570-7124
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10634T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU76963Medicare UPIN
CASD0106340Medicare ID - Type Unspecified