Provider Demographics
NPI:1265438766
Name:BARKER, MARK R (OD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:R
Last Name:BARKER
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:PO BOX U
Mailing Address - Street 2:
Mailing Address - City:BONNERS FERRY
Mailing Address - State:ID
Mailing Address - Zip Code:83805-1280
Mailing Address - Country:US
Mailing Address - Phone:208-267-2020
Mailing Address - Fax:208-267-8748
Practice Address - Street 1:7177 MAIN ST
Practice Address - Street 2:
Practice Address - City:BONNERS FERRY
Practice Address - State:ID
Practice Address - Zip Code:83805
Practice Address - Country:US
Practice Address - Phone:208-267-2020
Practice Address - Fax:208-267-8748
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID0-541152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID001963000Medicaid
ID001963000Medicaid