Basic Information
| Provider Information | |||||||||
| NPI: | 1639419328 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MARK SIVERD OD LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 119 PRESIDENT MADISON DR | ||||||||
| Address2: | |||||||||
| City: | MADISONVILLE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 704479486 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9856356943 | ||||||||
| FaxNumber: | 9856356948 | ||||||||
| Practice Location | |||||||||
| Address1: | 880 N HIGHWAY 190 | ||||||||
| Address2: | |||||||||
| City: | COVINGTON | ||||||||
| State: | LA | ||||||||
| PostalCode: | 704335147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9856356943 | ||||||||
| FaxNumber: | 9856356948 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/18/2013 | ||||||||
| LastUpdateDate: | 02/18/2013 | ||||||||
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| AuthorizedOfficialLastName: | SIVERD | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
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| AuthorizedOfficialTitleorPosition: | OPTOMETRIST | ||||||||
| AuthorizedOfficialTelephone: | 9856356943 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | OD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 78933OT | LA | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
No ID Information.