Provider Demographics
NPI:1841366028
Name:WINTER, MARK THOMAS
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:THOMAS
Last Name:WINTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6254
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32503-0254
Mailing Address - Country:US
Mailing Address - Phone:850-380-4332
Mailing Address - Fax:850-477-7025
Practice Address - Street 1:6810 N DAVIS HWY
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-6304
Practice Address - Country:US
Practice Address - Phone:850-477-0194
Practice Address - Fax:850-477-7025
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2008-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 2316152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL260283946OtherNVA
FL07885400Medicaid
FL260283946OtherSUPERIOR
FL260283946OtherTRICARE STANDARD
FLFL2316OtherEYEMED
FL260283946OtherAETNA
FL44939OtherAVESIS
FL47093OtherSPECTERA
FL260283946OtherAETNA
FL07885400Medicaid
FL260283946OtherNVA