Provider Demographics
NPI:1992816904
Name:VALLO, MARK B (OD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:B
Last Name:VALLO
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 1:655 WAGNER AVE
Mailing Address - Street 2:P.O. BOX 629
Mailing Address - City:GREENVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45331-2648
Mailing Address - Country:US
Mailing Address - Phone:937-548-4940
Mailing Address - Fax:937-548-1847
Practice Address - Street 1:655 WAGNER AVE
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:OH
Practice Address - Zip Code:45331-2648
Practice Address - Country:US
Practice Address - Phone:937-548-4940
Practice Address - Fax:937-548-1847
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3153152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9275251Medicare PIN
OHT46711Medicare UPIN
OH0636930001Medicare PIN