Provider Demographics
NPI:1720076433
Name:RAKOCZY, MARK STEVEN (OD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:STEVEN
Last Name:RAKOCZY
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 1:141 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:PA
Mailing Address - Zip Code:15537-1259
Mailing Address - Country:US
Mailing Address - Phone:814-652-6221
Mailing Address - Fax:814-652-9143
Practice Address - Street 1:141 E MAIN ST
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:PA
Practice Address - Zip Code:15537-1259
Practice Address - Country:US
Practice Address - Phone:814-652-6221
Practice Address - Fax:814-652-9143
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-07
Last Update Date:2017-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000168152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0010341570002Medicaid
PA204217OtherUPMC
PA410046691Medicare PIN
PA204217OtherUPMC
PA0010341570002Medicaid
PA0689940001Medicare NSC