Provider Demographics
NPI:1831196377
Name:COUTS, MARK ALAN (OD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ALAN
Last Name:COUTS
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 1:202 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CULVER
Mailing Address - State:IN
Mailing Address - Zip Code:46511-1516
Mailing Address - Country:US
Mailing Address - Phone:574-842-3372
Mailing Address - Fax:574-842-3372
Practice Address - Street 1:202 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CULVER
Practice Address - State:IN
Practice Address - Zip Code:46511-1516
Practice Address - Country:US
Practice Address - Phone:574-842-3372
Practice Address - Fax:574-842-3372
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-30
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002062A, B152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100279120AMedicaid
INU18745Medicare UPIN
IN100279120AMedicaid
IN0543900001Medicare NSC