Provider Demographics
NPI:1952092314
Name:HERRON, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:HERRON
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 1:10 CHERRY RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:NORTH EASTON
Mailing Address - State:MA
Mailing Address - Zip Code:02356-1357
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:250 GRANITE ST STE 2069
Practice Address - Street 2:
Practice Address - City:BRAINTREE
Practice Address - State:MA
Practice Address - Zip Code:02184-2804
Practice Address - Country:US
Practice Address - Phone:781-849-9944
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-17
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MA9017152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program