Provider Demographics
NPI:1922102425
Name:FERRIS, MARK C
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:C
Last Name:FERRIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 19TH ST E
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:AL
Mailing Address - Zip Code:35501-5413
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:309 19TH ST E
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:AL
Practice Address - Zip Code:35501-5413
Practice Address - Country:US
Practice Address - Phone:205-221-2033
Practice Address - Fax:205-221-2035
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2007-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS-677-TA-182152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000038536Medicaid
ALU21201Medicare UPIN
AL000038536Medicaid