Basic Information
| Provider Information | |||||||||
| NPI: | 1295731214 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SALOPEK | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | D. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1920 EYRIE CT | ||||||||
| Address2: | APT 201 | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276064745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198894438 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4170 FAYETTEVILLE RD | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276033606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197722020 | ||||||||
| FaxNumber: | 9197728818 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2005 | ||||||||
| LastUpdateDate: | 12/11/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152WC0802X | 1511 | NC | N | Eye and Vision Services Providers | Optometrist | Corneal and Contact Management | 152W00000X | 1511 | NC | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 89093R4 | 05 | NC | MEDICAID | P00245416 | 01 | NC | RR MEDICARE | OTHER | 093R4 | 01 | NC | BCBS PIN | OTHER |