Basic Information
| Provider Information | |||||||||
| NPI: | 1740374305 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MARK D PIFER & CHRIS A CALAWAY | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MOBIL OPTOMETRIC SERVICE LLC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 31 CONSERVATORY DR | ||||||||
| Address2: | |||||||||
| City: | BARBERTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3307451969 | ||||||||
| FaxNumber: | 3307539162 | ||||||||
| Practice Location | |||||||||
| Address1: | 31 CONSERVATORY DR | ||||||||
| Address2: | |||||||||
| City: | BARBERTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3307451969 | ||||||||
| FaxNumber: | 3307539162 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 06/19/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CALAWAY | ||||||||
| AuthorizedOfficialFirstName: | CHRIS | ||||||||
| AuthorizedOfficialMiddleName: | ALLAN | ||||||||
| AuthorizedOfficialTitleorPosition: | PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 3307451969 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | O.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332H00000X | N | Suppliers | Eyewear Supplier (Equipment, not the service) | 152W00000X | 3522 | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 0812188 | 05 | OH | MEDICAID |