Provider Demographics
NPI:1396753455
Name:CENEVIVA, MARK ALLEN (OD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALLEN
Last Name:CENEVIVA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:977 NEWARK GRANVILLE RD
Mailing Address - Street 2:
Mailing Address - City:GRANVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43023-1454
Mailing Address - Country:US
Mailing Address - Phone:740-522-2553
Mailing Address - Fax:740-522-5346
Practice Address - Street 1:911 HEBRON RD
Practice Address - Street 2:
Practice Address - City:HEATH
Practice Address - State:OH
Practice Address - Zip Code:43056-1182
Practice Address - Country:US
Practice Address - Phone:740-522-2553
Practice Address - Fax:740-522-5346
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3785152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0792316Medicaid
OH0792316Medicaid
OHCEO689181Medicare ID - Type Unspecified