Provider Demographics
NPI:1003305657
Name:MARK P MAHER OPTOMETRIC CORPORATION
Entity type:Organization
Organization Name:MARK P MAHER OPTOMETRIC CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:J
Authorized Official - Last Name:CONNOR
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:408-779-2266
Mailing Address - Street 1:419 VINEYARD TOWN CTR
Mailing Address - Street 2:
Mailing Address - City:MORGAN HILL
Mailing Address - State:CA
Mailing Address - Zip Code:95037-5631
Mailing Address - Country:US
Mailing Address - Phone:408-779-2266
Mailing Address - Fax:
Practice Address - Street 1:419 VINEYARD TOWN CTR
Practice Address - Street 2:
Practice Address - City:MORGAN HILL
Practice Address - State:CA
Practice Address - Zip Code:95037-5631
Practice Address - Country:US
Practice Address - Phone:
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-08
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7988T261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
=========OtherTIN