Provider Demographics
NPI:1972594224
Name:MANARY, MARK A (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:MANARY
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 1:2421 W EDGEWOOD DR
Mailing Address - Street 2:STE A
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109-5844
Mailing Address - Country:US
Mailing Address - Phone:573-636-2103
Mailing Address - Fax:
Practice Address - Street 1:2421 W EDGEWOOD DR
Practice Address - Street 2:STE A
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-5844
Practice Address - Country:US
Practice Address - Phone:573-636-2103
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-03
Last Update Date:2013-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOTO3364152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO318903804Medicaid
MO318903804Medicaid