Provider Demographics
NPI:1336245745
Name:VARNUM, MARK STEPHEN (OD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:STEPHEN
Last Name:VARNUM
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 1:11 BANGOR MALL BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401
Mailing Address - Country:US
Mailing Address - Phone:207-947-2385
Mailing Address - Fax:207-947-2430
Practice Address - Street 1:11 BANGOR MALL BOULEVARD
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401
Practice Address - Country:US
Practice Address - Phone:207-947-2385
Practice Address - Fax:207-947-2430
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2013-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOPT747152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME123860099Medicaid
ME123860099Medicaid
T31383Medicare UPIN