Provider Demographics
NPI:1699884882
Name:HERRON, MARK A (OD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:HERRON
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 1:8614 WESTWOOD CENTER DR FL 9
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-2442
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:571-223-6780
Practice Address - Street 1:12094 MONTGOMERY RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45249-1729
Practice Address - Country:US
Practice Address - Phone:513-774-0999
Practice Address - Fax:513-774-0547
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4746 / T1550152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
311645431OtherU.H.C.
OH000000122749OtherANTHEM
311645431OtherAETNA
311645431OtherHUMANA
OH000000122749OtherANTHEM
311645431OtherHUMANA
U77318Medicare UPIN