Provider Demographics
NPI:1780890541
Name:DR MARK D DENNEY OD PA
Entity type:Organization
Organization Name:DR MARK D DENNEY OD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:D
Authorized Official - Last Name:DENNEY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:208-523-3141
Mailing Address - Street 1:1340 S AMMON RD
Mailing Address - Street 2:
Mailing Address - City:AMMON
Mailing Address - State:ID
Mailing Address - Zip Code:83406-5810
Mailing Address - Country:US
Mailing Address - Phone:208-523-3141
Mailing Address - Fax:208-525-2661
Practice Address - Street 1:1340 S. AMMON ROAD
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83406
Practice Address - Country:US
Practice Address - Phone:208-523-3141
Practice Address - Fax:208-525-2661
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP1012152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDV3918OtherBLUE CROSS
ID000010026621OtherBLUE SHIELD
ID167539OtherCOLE
ID805561900Medicaid
IDV3918OtherBLUE CROSS
ID167539OtherCOLE