Individual
DR. MARK JOSEPH BANNON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
OD
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
888
CT
332H00000X
Eyewear Supplier
Primary
888
CT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
004101549
—
CT
Enumeration date
01/26/2007
Last updated
11/03/2008
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