Provider Demographics
NPI:1164491718
Name:DEAN, MARK TRACY (OD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:TRACY
Last Name:DEAN
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 1:4886 SOCASTEE BLVD
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29588-7245
Mailing Address - Country:US
Mailing Address - Phone:843-293-1555
Mailing Address - Fax:
Practice Address - Street 1:4886 SOCASTEE BLVD
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29588-7245
Practice Address - Country:US
Practice Address - Phone:843-293-1555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-16
Last Update Date:2011-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC679152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCD06795Medicaid
SCT250439990Medicare PIN
SCT25043Medicare UPIN