Provider Demographics
NPI:1407848724
Name:SUKOENIG, MARK RICHARD (OD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:RICHARD
Last Name:SUKOENIG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9537 DESTINYUSA DRIVE
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13204-9501
Mailing Address - Country:US
Mailing Address - Phone:315-474-8490
Mailing Address - Fax:315-474-8676
Practice Address - Street 1:9537 DESTINYUSA DRIVE
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13204-9501
Practice Address - Country:US
Practice Address - Phone:315-474-8490
Practice Address - Fax:315-474-8676
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2016-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTU003680-1152W00000X, 152WL0500X
NYTUV003680152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYTU003680-1OtherNY OPTOMETRY LICENSE #
NY54017BMedicare ID - Type UnspecifiedMEDICARE NUMBER
NYTU003680-1OtherNY OPTOMETRY LICENSE #