Provider Demographics
NPI:1871690883
Name:SIVERD, MARK (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:SIVERD
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 1:119 PRESIDENT MADISON DR
Mailing Address - Street 2:
Mailing Address - City:MADISONVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70447-9486
Mailing Address - Country:US
Mailing Address - Phone:985-264-5772
Mailing Address - Fax:
Practice Address - Street 1:880 N HIGHWAY 190
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-5147
Practice Address - Country:US
Practice Address - Phone:985-867-8708
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA789330T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1173061Medicaid
LA1173061Medicaid
LAT69537Medicare UPIN