Provider Demographics
NPI:1932405784
Name:AXFORD, MARK W (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:W
Last Name:AXFORD
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:5415 S FARM ROAD 141
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65810-2220
Mailing Address - Country:US
Mailing Address - Phone:843-566-4105
Mailing Address - Fax:417-544-8675
Practice Address - Street 1:640 W CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65806-1016
Practice Address - Country:US
Practice Address - Phone:417-869-3937
Practice Address - Fax:417-544-8675
Is Sole Proprietor?:No
Enumeration Date:2011-01-26
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2019009094152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDA16621Medicaid
SCDA9566Medicaid
SCAA72045911OtherMEDICARE PTAN
SCDA9628Medicaid
SCDA16621Medicaid
SCAA72045911OtherMEDICARE PTAN
SCDA9628Medicaid