Provider Demographics
NPI:1124834486
Name:DUFFY, MARK A (RCIS)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:DUFFY
Suffix:
Gender:M
Credentials:RCIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1252 OLD JONESBORO RD
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:TN
Mailing Address - Zip Code:37620-5566
Mailing Address - Country:US
Mailing Address - Phone:276-608-6040
Mailing Address - Fax:
Practice Address - Street 1:1 MEDICAL PARK BLVD
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-7430
Practice Address - Country:US
Practice Address - Phone:423-844-2772
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-10
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN00131006156F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156F00000XEye and Vision Services ProvidersTechnician/Technologist