Provider Demographics
NPI:1639171960
Name:BORSUK, MARK P (OD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:P
Last Name:BORSUK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:108 OLDE TOWNE AVE
Mailing Address - Street 2:STE 16
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20877-6005
Mailing Address - Country:US
Mailing Address - Phone:240-631-2255
Mailing Address - Fax:240-631-2299
Practice Address - Street 1:108 OLDE TOWNE AVE
Practice Address - Street 2:STE 16
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20877-6005
Practice Address - Country:US
Practice Address - Phone:240-631-2255
Practice Address - Fax:240-631-2299
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2007-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA1522152WC0802X, 152WV0400X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCU76960Medicare PIN
DCG01801M01Medicare PIN