Provider Demographics
NPI:1962569681
Name:DENNEY, MARK D (OD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:D
Last Name:DENNEY
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 1:1340 S AMMON RD
Mailing Address - Street 2:
Mailing Address - City:AMMON
Mailing Address - State:ID
Mailing Address - Zip Code:83406-5810
Mailing Address - Country:US
Mailing Address - Phone:208-523-3141
Mailing Address - Fax:208-525-2661
Practice Address - Street 1:1340 S AMMON RD
Practice Address - Street 2:
Practice Address - City:AMMON
Practice Address - State:ID
Practice Address - Zip Code:83406-5810
Practice Address - Country:US
Practice Address - Phone:208-523-3141
Practice Address - Fax:208-525-2661
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2010-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP1012152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010026621OtherBLUE SHIELD
ID805561900Medicaid
IDV3918OtherBLUE CROSS
ID167539OtherCOLE
ID805561900Medicaid
ID000010026621OtherBLUE SHIELD
ID805561900Medicaid