Provider Demographics
NPI:1144356726
Name:SANITATE, MARK JOHN (OD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:JOHN
Last Name:SANITATE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:140 MACOMB PL
Mailing Address - Street 2:
Mailing Address - City:MOUNT CLEMENS
Mailing Address - State:MI
Mailing Address - Zip Code:48043-5651
Mailing Address - Country:US
Mailing Address - Phone:586-468-7370
Mailing Address - Fax:586-468-7682
Practice Address - Street 1:3160 GRATIOT BLVD
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:MI
Practice Address - Zip Code:48040-1488
Practice Address - Country:US
Practice Address - Phone:810-364-5520
Practice Address - Fax:810-364-6545
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI4901003258152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4109640001Medicare ID - Type Unspecified