Provider Demographics
NPI:1336233931
Name:ELKINSON, MARK E (OD PA)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:E
Last Name:ELKINSON
Suffix:
Gender:M
Credentials:OD PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:200 GORHAM RD
Mailing Address - Street 2:SUITE 940
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-2409
Mailing Address - Country:US
Mailing Address - Phone:207-761-9054
Mailing Address - Fax:207-879-9003
Practice Address - Street 1:200 GORHAM RD
Practice Address - Street 2:SUITE 940
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-2409
Practice Address - Country:US
Practice Address - Phone:207-761-9054
Practice Address - Fax:207-879-9003
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2012-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOPT758152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME120910000Medicaid
ME120910000Medicaid
MEMM4425Medicare PIN