Provider Demographics
NPI:1255318861
Name:AINSWORTH, MARK M (OD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:M
Last Name:AINSWORTH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:394 E STATE ST
Mailing Address - Street 2:
Mailing Address - City:HERKIMER
Mailing Address - State:NY
Mailing Address - Zip Code:13350-2026
Mailing Address - Country:US
Mailing Address - Phone:315-866-9667
Mailing Address - Fax:315-866-9668
Practice Address - Street 1:394 E STATE ST
Practice Address - Street 2:
Practice Address - City:HERKIMER
Practice Address - State:NY
Practice Address - Zip Code:13350-2026
Practice Address - Country:US
Practice Address - Phone:315-866-9667
Practice Address - Fax:315-866-9668
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-23
Last Update Date:2009-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV005303-1332H00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01912927Medicaid
NY493OtherDAVIS
NY522109986OtherBCBS
NY595064OtherMVP
NYNY5303OtherVISION BENEFITS OF AMERIC
NY117251OtherEYEMED
NY05742OtherSPECTERA
NY55957BMedicare PIN
NYNY5303OtherVISION BENEFITS OF AMERIC