Provider Demographics
NPI:1740274885
Name:SHIREY, MARK WADE (OD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:WADE
Last Name:SHIREY
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 1:7921 TANNER WILLIAMS RD
Mailing Address - Street 2:SUITE H
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36608-8308
Mailing Address - Country:US
Mailing Address - Phone:251-634-2144
Mailing Address - Fax:251-634-2145
Practice Address - Street 1:7921 TANNER WILLIAMS RD
Practice Address - Street 2:SUITE H
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36608-8312
Practice Address - Country:US
Practice Address - Phone:251-634-2144
Practice Address - Fax:251-634-2145
Is Sole Proprietor?:No
Enumeration Date:2005-09-06
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS-968-TA-542152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51514440OtherBCBS PROVIDER NUMBER
ALS-968-TA-542OtherSTATE LICENSE NUMBER
ALMS0603553OtherDEA NUMBER
ALMS0603553OtherDEA NUMBER
ALS-968-TA-542OtherSTATE LICENSE NUMBER
AL51514440OtherBCBS PROVIDER NUMBER