Basic Information
| Provider Information | |||||||||
| NPI: | 1639135817 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DUNBAR | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | T. | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 900 NW 17TH ST | ||||||||
| Address2: | BOX 016960 M851 | ||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331361119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3053266132 | ||||||||
| FaxNumber: | 3052438470 | ||||||||
| Practice Location | |||||||||
| Address1: | 900 NW 17TH ST | ||||||||
| Address2: | BOX 016960 M851 | ||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331361119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3053266132 | ||||||||
| FaxNumber: | 3052438470 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2006 | ||||||||
| LastUpdateDate: | 03/21/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OPC2231 | FL | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 6203248-00 | 05 | FL | MEDICAID |