Provider Demographics
NPI:1912979311
Name:HURST, MARK C (OPTOMETRIST, LTD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:C
Last Name:HURST
Suffix:
Gender:M
Credentials:OPTOMETRIST, LTD
Other - Prefix:DR
Other - First Name:MARK
Other - Middle Name:C
Other - Last Name:HURST
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:4 WESTWOOD DRIVE
Mailing Address - Street 2:
Mailing Address - City:MT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864
Mailing Address - Country:US
Mailing Address - Phone:618-242-7810
Mailing Address - Fax:618-242-1867
Practice Address - Street 1:4 WESTWOOD DRIVE
Practice Address - Street 2:
Practice Address - City:MT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864
Practice Address - Country:US
Practice Address - Phone:618-242-7810
Practice Address - Fax:618-242-1867
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-02
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046007393152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0622930001OtherADMINASTAR FEDERAL
1851561575OtherJURISDICTION B DME MAC
410046689OtherRR MEDICARE
0622930001OtherADMINASTAR FEDERAL
735510Medicare ID - Type Unspecified