Provider Demographics
NPI:1356930630
Name:NIKAJ, MARK (OD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:NIKAJ
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 1:100 TOWN CENTER DR APT 5306
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:GA
Mailing Address - Zip Code:31405-9566
Mailing Address - Country:US
Mailing Address - Phone:562-774-6450
Mailing Address - Fax:
Practice Address - Street 1:7917 ABERCORN ST
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406-3414
Practice Address - Country:US
Practice Address - Phone:912-421-3350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-12
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT34786TLG152W00000X
GAOPT003325152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist