Provider Demographics
NPI:1396724662
Name:CUTLER, MARK GONZALES (OD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:GONZALES
Last Name:CUTLER
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 1:3412 TROWBRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75036-8188
Mailing Address - Country:US
Mailing Address - Phone:317-678-0572
Mailing Address - Fax:
Practice Address - Street 1:541 E SANDY LAKE RD
Practice Address - Street 2:
Practice Address - City:COPPELL
Practice Address - State:TX
Practice Address - Zip Code:75019-3090
Practice Address - Country:US
Practice Address - Phone:972-393-3937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-13
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003130A152W00000X
TX9965T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX9965TOtherOPTOMETRY LICENSE
INP00190498OtherRAILROAD / TRAVELERS
IN200402670AMedicaid
IN000000351184OtherANTHEM
IN000000351184OtherANTHEM