Provider Demographics
NPI:1801983143
Name:MARK A. MANARY, O.D., LLC
Entity type:Organization
Organization Name:MARK A. MANARY, O.D., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:MANARY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:573-489-2499
Mailing Address - Street 1:3505 BRAY AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-0794
Mailing Address - Country:US
Mailing Address - Phone:573-489-2499
Mailing Address - Fax:573-636-2103
Practice Address - Street 1:415 CONLEY RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-6468
Practice Address - Country:US
Practice Address - Phone:573-499-1945
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOTO3364152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO318903838Medicaid