Provider Demographics
NPI:1073516241
Name:CAROLAN, MARK GERARD (OD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:GERARD
Last Name:CAROLAN
Suffix:
Gender:
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5430 FREDERICKSBURG RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3539
Mailing Address - Country:US
Mailing Address - Phone:210-340-1212
Mailing Address - Fax:210-340-1505
Practice Address - Street 1:5430 FREDERICKSBURG RD STE 100
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3539
Practice Address - Country:US
Practice Address - Phone:210-340-1212
Practice Address - Fax:210-525-9617
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-23
Last Update Date:2025-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX03767TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX133537404Medicaid
TXT78943Medicare UPIN
TX81233EMedicare ID - Type Unspecified
TX00E40VMedicare ID - Type Unspecified