Provider Demographics
NPI:1063538981
Name:BAUER, MARK T (LDO)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:T
Last Name:BAUER
Suffix:
Gender:M
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 PUTNAM ST
Mailing Address - Street 2:STE102
Mailing Address - City:MARIETTA
Mailing Address - State:OH
Mailing Address - Zip Code:45750-3042
Mailing Address - Country:US
Mailing Address - Phone:740-373-7300
Mailing Address - Fax:740-373-7388
Practice Address - Street 1:206 PUTNAM ST
Practice Address - Street 2:STE102
Practice Address - City:MARIETTA
Practice Address - State:OH
Practice Address - Zip Code:45750-3042
Practice Address - Country:US
Practice Address - Phone:740-373-7300
Practice Address - Fax:740-373-7388
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3132S156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician