Provider Demographics
NPI:1730183351
Name:HALL, MARK W (OD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:W
Last Name:HALL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:90 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:WINDER
Mailing Address - State:GA
Mailing Address - Zip Code:30680-1714
Mailing Address - Country:US
Mailing Address - Phone:770-867-2505
Mailing Address - Fax:770-867-8668
Practice Address - Street 1:90 CHURCH ST
Practice Address - Street 2:
Practice Address - City:WINDER
Practice Address - State:GA
Practice Address - Zip Code:30680-1714
Practice Address - Country:US
Practice Address - Phone:770-867-2505
Practice Address - Fax:770-867-8668
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2014-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA721T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAT97620Medicare UPIN
GA0590190001Medicare NSC