Provider Demographics
NPI:1306125166
Name:HAVERA, MARK A (OD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:HAVERA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:40 E NORTH ST
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:MO
Mailing Address - Zip Code:63025-1205
Mailing Address - Country:US
Mailing Address - Phone:636-200-4393
Mailing Address - Fax:636-938-2650
Practice Address - Street 1:6663 EDWARDSVILLE CROSSING DR
Practice Address - Street 2:STE B
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025-2704
Practice Address - Country:US
Practice Address - Phone:618-659-2320
Practice Address - Fax:618-655-0375
Is Sole Proprietor?:No
Enumeration Date:2011-08-11
Last Update Date:2014-10-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL046010454152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist