Provider Demographics
NPI:1962841072
Name:MARK, KEION (OD,)
Entity Type:Individual
Prefix:DR
First Name:KEION
Middle Name:
Last Name:MARK
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 1:2161 E COUNTY ROAD 540A # 254
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-3794
Mailing Address - Country:US
Mailing Address - Phone:484-477-2579
Mailing Address - Fax:
Practice Address - Street 1:801 E BAKER ST
Practice Address - Street 2:
Practice Address - City:PLANT CITY
Practice Address - State:FL
Practice Address - Zip Code:33563-3652
Practice Address - Country:US
Practice Address - Phone:813-653-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-21
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ270A00645900152W00000X
PAOEG002772152W00000X
FLOPC5282152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist