Provider Demographics
NPI:1114192044
Name:MARK F. KAPUSTA O.D. INC
Entity Type:Organization
Organization Name:MARK F. KAPUSTA O.D. INC
Other - Org Name:MARK F. KAPUSTA O.D.
Other - Org Type:Other Name
Authorized Official - Title/Position:MEDICAL SECRETARY
Authorized Official - Prefix:MRS
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:RENAE
Authorized Official - Last Name:MCCALLION
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-944-5155
Mailing Address - Street 1:30851 EUCLID AVE
Mailing Address - Street 2:SUITE 4
Mailing Address - City:WILLOUGHBY
Mailing Address - State:OH
Mailing Address - Zip Code:44094-3198
Mailing Address - Country:US
Mailing Address - Phone:440-944-5155
Mailing Address - Fax:440-943-9460
Practice Address - Street 1:30851 EUCLID AVE
Practice Address - Street 2:SUITE 4
Practice Address - City:WILLOUGHBY
Practice Address - State:OH
Practice Address - Zip Code:44094-3198
Practice Address - Country:US
Practice Address - Phone:440-944-5155
Practice Address - Fax:440-943-9460
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-22
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3511T508152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0720050001Medicare NSC