Provider Demographics
NPI:1952339145
Name:SKINNER, MARK LOWREY (OD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:LOWREY
Last Name:SKINNER
Suffix:
Gender:M
Credentials:OD
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 2200
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92334-2200
Mailing Address - Country:US
Mailing Address - Phone:909-822-1115
Mailing Address - Fax:909-822-6346
Practice Address - Street 1:8275 SIERRA AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335-3557
Practice Address - Country:US
Practice Address - Phone:909-822-1115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9363T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT88739Medicare UPIN
CASD0093630Medicare ID - Type Unspecified