Provider Demographics
NPI:1063747145
Name:BREEDEN, MARK ALBERT (OD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALBERT
Last Name:BREEDEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:MARK
Other - Middle Name:ALBERT
Other - Last Name:BREEDEN OD, INC
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1801 POPLAR DR APT 44
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-4675
Mailing Address - Country:US
Mailing Address - Phone:541-840-3168
Mailing Address - Fax:
Practice Address - Street 1:11500 HANNON RD
Practice Address - Street 2:
Practice Address - City:EAGLE POINT
Practice Address - State:OR
Practice Address - Zip Code:97524-9598
Practice Address - Country:US
Practice Address - Phone:541-849-3168
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-07
Last Update Date:2011-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OR3410ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program